Current Procedural Terminology (CPT) codes form the standardized language used for medical billing and documentation across the United States. Managed by the American Medical Association (AMA), these codes provide a uniform way to describe specific medical services and procedures performed by healthcare providers. Accurate CPT coding ensures that services are properly documented and that providers receive appropriate reimbursement from insurance payers.
The Purpose of This Preventative Service
CPT code 99385 specifically represents an initial comprehensive preventative medicine evaluation and management service for a new adult patient. This routine check-up focuses on maintaining health and preventing disease before symptoms appear. It is fundamentally different from a standard office visit, which focuses on diagnosing or treating a specific illness or complaint.
The service focuses on identifying potential health risks and providing guidance to mitigate them, rather than addressing acute or chronic health problems. For example, a patient with no current symptoms might receive screening for hypertension or diabetes risk factors. This preventative approach helps to catch potential health issues early, leading to better long-term health outcomes.
Specific Criteria for Code Usage
The application of CPT code 99385 is strictly defined by two administrative criteria related to the patient’s status and age. First, the code applies only to a “new patient.” This is defined as an individual who has not received any professional services from the physician or another physician of the same specialty in the same group practice within the past three years.
Second, the patient must fall within a specific age demographic at the time of the service, ranging from 18 through 39 years old. If a patient meets the new patient criteria but is 40 or older, a different CPT code, such as 99386, would be used instead. These rigid parameters ensure that the service is billed correctly and corresponds to the age-appropriate recommendations for screenings and counseling.
Components of the Annual Exam
The service documented by CPT code 99385 includes several specific elements that distinguish it from a basic physical examination. The provider must complete a comprehensive history review, which covers medical, family, and social history, including a detailed review of all organ systems. A general physical examination is also performed, appropriate for the patient’s age and gender.
A defining feature of this preventative service is the inclusion of counseling, anticipatory guidance, and risk factor reduction interventions. The provider is expected to discuss various health behaviors, such as diet, exercise, substance use, and sexual health, to promote wellness. The visit also involves ordering appropriate age- and gender-specific laboratory or diagnostic procedures, and reviewing immunization status.
Navigating Insurance and Billing
Understanding how CPT code 99385 is handled by insurance is important for avoiding unexpected costs. Under the Affordable Care Act (ACA), most private insurance plans are required to cover preventative services, like 99385, at 100% with no patient cost-sharing, provided the provider is in-network. This means the patient typically does not have a copay, coinsurance, or deductible for the preventative portion of the visit.
A common source of confusion arises when a patient addresses a separate, new medical problem during the same visit as their preventative exam. If the provider evaluates and manages a significant, separately identifiable problem—such as a new rash or a sinus infection—in addition to the routine physical, they can bill for both services. The CPT code for the problem-focused service (often an Evaluation and Management code like 99203) is billed alongside 99385, and it must be accompanied by a special marker called Modifier 25.
The use of Modifier 25 indicates that the problem-focused visit was distinct from the preventative service. While the 99385 portion remains fully covered, the problem-focused service may be subject to the patient’s standard cost-sharing, like copays or deductibles. Patients should verify their plan’s specific coverage details with their insurance company before the appointment to understand potential out-of-pocket expenses.