CPT codes are a standardized set of numerical and alphanumeric codes used by healthcare providers in the United States to describe and report medical, surgical, and diagnostic services to payers. This system ensures uniformity in medical records and billing. CPT Code 99385 is designated for a specific type of preventive healthcare service, representing a comprehensive evaluation for individuals entering the adult phase of life. Understanding this code helps patients and providers recognize the scope of services covered under this wellness visit.
The Scope of CPT 99385
CPT code 99385 is defined as an “Initial Comprehensive Preventive Medicine Evaluation and Management.” This code is designed to capture a thorough health assessment for an individual who is new to a physician or group practice. A patient is considered “new” if they have 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.
The application of this code is strictly limited to individuals who are 18 through 39 years of age. This initial comprehensive visit is a valuable opportunity to establish a health baseline and address emerging adult health risks. The service is focused entirely on health maintenance and risk assessment, rather than the evaluation or treatment of an existing illness.
Components of the Preventive Exam
The service represented by CPT 99385 includes required components that define the comprehensive nature of the visit.
The provider must complete an age- and gender-appropriate history, which includes a detailed review of the patient’s past medical, family, and social history. This extensive history helps uncover genetic predispositions or lifestyle factors that could increase the risk of disease later in life.
A comprehensive physical examination is also a mandatory part of the service. It is guided by the patient’s age and general risk factors, typically including checking vital signs, assessing general appearance, and performing age-appropriate screenings. The goal of the physical assessment is to establish a baseline of health and detect any physical abnormalities in their early stages.
A significant portion of the visit is dedicated to counseling, anticipatory guidance, and risk factor reduction interventions. This involves discussing health behaviors like diet, exercise, and weight management, as well as addressing substance use, such as smoking cessation and alcohol consumption. Providers also offer guidance on safety and sexual health, tailoring the discussion to the patient’s specific needs and lifestyle.
Finally, the service includes the ordering of appropriate laboratory or diagnostic procedures and a review of immunization status. Common screenings may include calculating Body Mass Index (BMI), checking blood pressure, and evaluating lipid panels for patients with risk factors. The provider ensures the patient is up-to-date on recommended vaccines and plans any necessary follow-up testing.
When 99385 Should Not Be Used
The designation of CPT 99385 as an “initial” code means it cannot be used for subsequent preventive visits with the same physician or group practice. Once a new patient has received this service, their next preventive exam for the same age group would be classified under the “established patient” code, CPT 99395. The determination of whether a patient is new or established is based on the three-year rule.
CPT 99385 is strictly reserved for preventive services and is not intended for a problem-focused visit. If a patient presents with a new or acute illness, the evaluation and management of that specific problem is a separate service. The provider must use a separate Evaluation and Management (E/M) code (e.g., 99202–99215) to report the work associated with the illness.
When a patient receives both a preventive exam and treatment for a significant, separately identifiable medical problem during the same visit, the provider must append modifier 25 to the problem-focused E/M code. This modifier signals to the payer that the work for the problem was distinct and required additional effort beyond the scope of the comprehensive preventive service.