Is 99395 an E&M code?

CPT code 99395 is billed for a periodic, comprehensive preventive medicine reevaluation and management visit for an established patient aged 18 to 39 years.

Patient and Visit Criteria

• Patient Status: Must be an established patient (seen by the provider or same-specialty group within the past 3 years).
• Age Range: 18 through 39 years old.
• Visit Type: Routine wellness exam or annual physical without a primary acute or symptom-driven complaint.

Included Services

• Age- and gender-appropriate comprehensive history and physical examination.
• Counseling, anticipatory guidance, and risk factor reduction interventions.
• Ordering of appropriate laboratory or diagnostic procedures.

Coding and Billing Rules

• Diagnosis Codes: Use primary preventive ICD-10 codes (such as Z00.00 or Z00.01 for general adult medical examinations). Avoid symptom-based or chronic disease primary codes for the preventive line.
• Medicare Exclusion: Medicare Part B does not cover CPT 99395; use specific HCPCS codes like G0402, G0438, or G0439 instead.
• Simultaneous Problem Visits: If a significant, separate acute or chronic problem is addressed during the same visit, bill the appropriate outpatient E/M code (99211–99215) alongside 99395 with Modifier -25 appended to the problem-oriented E/M code, supported by distinct documentation.
• Additional Services: Separate screening tools (like a PHQ-9 using code 96127) or specific interventions (like tobacco cessation counseling 99406) may be billable separately if allowed by the payer.

For a comprehensive breakdown of coding rules, you can review guidelines from resources like Optimantra and Avenue Billing Services.

Yes, CPT code 99214 and CPT code 99396 can be billed together when the provider addresses a significant, separately identifiable problem-oriented service during the same encounter as a routine preventive visit.

According to a consensus among billing professionals on Facebook, both codes are allowed under specific criteria:

Key Billing Rules

• Modifier 25: You must append Modifier 25 to the problem-oriented E/M code (99214), not to the preventive code (99396). Putting the modifier on the preventive line will cause a claim denial.
• Separately Identifiable: The medical record must clearly show that the work done for 99214 went beyond the routine screening, counseling, and history of the preventive visit (99396). Examples include evaluating new-onset hypertension or managing a flare-up of a chronic condition.
• Documentation: The provider's notes must feature a distinct chief complaint and separate medical decision-making (MDM) for the problem being addressed. Minor or incidental complaints do not qualify for dual billing.
• Payer Policies: Traditional Medicare does not cover 99396 (using Annual Wellness Visit codes instead), and commercial insurance rules vary by carrier. Always check specific payer guidelines.

Yes, CPT Code 99395 is technically classified under the Evaluation and Management (E/M) section of the CPT manual, but it specifically designates a preventive medicine service rather than a standard office/outpatient evaluation.

Code Details

• Definition: Periodic comprehensive preventive medicine reevaluation and management.
• Patient Age: Established adult patient aged 18 to 39 years.
• Focus: Routine wellness, health assessments, physical examinations, and anticipatory guidance/risk factor reduction, rather than managing a specific illness or acute symptom.

Key Distinctions

• Not Time- or MDM-Driven: Unlike office/outpatient E/M codes (such as 99211–99215), code 99395 is selected based on the patient's age and established status (seen within the past three years by the practice), not by the time spent or medical decision-making (MDM) complexity.
• Same-Day Billing: If a separate, distinct problem-oriented E/M service is performed during the same preventive visit, a standard E/M code can be billed alongside 99395, but you must append modifier 25 to the problem-oriented E/M code.

The main difference between CPT code 99395 and CPT code 99396 is the age range of the established patient receiving the comprehensive preventive medicine evaluation.

• CPT 99395: For established patients aged 18 through 39 years.
• CPT 99396: For established patients aged 40 through 64 years.

Key Details

• Patient Status: Both codes are for established patients (someone who has received professional services from the physician or another physician in the same group and specialty within the past three years).
• Scope of Service: Both cover a periodic, comprehensive preventive medicine reevaluation, including a history, physical examination, risk factor counseling, and age-appropriate screenings. However, code 99396 accounts for older age-specific screenings and risk discussions (such as mammography or colon cancer screening discussions) tailored to the 40–64 age bracket.
• Age Cutoff Rules: The patient's age on the date of service determines the correct code. If a patient turns 40 on or before the visit, you must use 99396; billing 99395 for a 40-year-old will typically trigger an age-range mismatch rejection from insurance payers.

Yes, CPT code 99395 is a preventive medicine service used for a comprehensive routine wellness visit.

Key Details for CPT Code 99395

• Patient Age: Established adults aged 18 through 39 years.
• Patient Status: Established patient (the patient has seen the provider or someone in the same medical group within the past three years).
• Services Included: Age-appropriate physical examination, medical history review, counseling, anticipatory guidance, risk factor reduction interventions, and ordering routine lab or diagnostic procedures.
• Billing/Coverage: Covered by most commercial ACA-compliant insurance plans, often without cost-sharing when billed with a preventive diagnosis code (like ICD-10 Z00.00 or Z00.01). Medicare generally excludes this code and uses HCPCS codes G0438 or G0439 instead.