CPT codes are standardized numerical identifiers used in the United States to report medical services to payers, such as insurance companies. CPT Code 99395 is a specific identifier designed for a patient encounter focused solely on maintaining wellness. This code reports a periodic comprehensive preventive medicine evaluation and management service.
Defining the Preventive Medicine Code
CPT Code 99395 officially describes a “Periodic Comprehensive Preventive Medicine Evaluation and Management” service for an established patient. It targets individuals between the ages of 18 and 39 years. This service is a routine, non-problem-focused visit intended to evaluate a person’s health when they are generally symptom-free. The code is used once per year to signify a health maintenance check, contrasting with visits focused on diagnosing or treating a specific illness.
The purpose of this visit is to perform a proactive assessment and provide guidance to prevent future health issues. Once a patient reaches the age of 40, the appropriate CPT code shifts to 99396, reflecting the different age-specific screenings and counseling necessary for that older demographic. This systematic use of age-specific codes ensures that the preventive services provided are tailored to the most relevant health risks for the patient’s stage of life.
What Happens During the Visit
The comprehensive nature of the CPT 99395 visit requires the healthcare provider to perform several specific components. The visit begins with an updated comprehensive health history, which includes a review of the patient’s past medical, family, and social history to identify potential risk factors. This history update is followed by a thorough physical examination appropriate for the patient’s age and gender.
Age-appropriate screening procedures are a significant part of the encounter. These may involve basic measurements like Body Mass Index (BMI), blood pressure screening, and screening for depression and substance use. The provider will also order necessary immunizations or laboratory tests, such as a cholesterol panel or cervical cancer screening, although the lab work itself is typically billed separately. The entire visit’s focus is on prevention, meaning any screenings are performed without an existing symptom or complaint.
Health Education and Counseling
A large portion of the visit is dedicated to health education and anticipatory guidance. This counseling focuses on lifestyle and behavioral health topics. The provider discusses the following areas to establish a personalized care plan for the coming year:
- Diet
- Exercise
- Substance use
- Injury prevention
- Reproductive health
- Sexual health
- Strategies for managing stress
How Code 99395 Affects Your Insurance Coverage
CPT Code 99395 has direct financial implications, as it is typically covered under the Affordable Care Act (ACA) mandate for preventive services. When billed correctly, this preventive service is often covered at 100% by the insurance plan. This means the patient generally has no out-of-pocket costs like a copay or deductible, though the benefit is usually limited to one preventive visit per year.
The critical nuance for this code lies in the distinction between preventive and diagnostic services. If the provider identifies a new problem or if the patient presents with a specific symptom that requires evaluation, the encounter shifts to include a diagnostic component. In this scenario, the provider may bill for the preventive service (99395) and an additional Evaluation and Management (E/M) code, such as 99213, using a modifier to indicate both services were performed.
The addition of a diagnostic E/M code means the patient may be responsible for a co-pay, co-insurance, or deductible payment for the diagnostic portion of the visit. For example, a routine cholesterol test ordered during the preventive visit is covered, but if the patient also asks the doctor to evaluate a new, persistent rash, the time spent addressing the rash may be billed as a separate, problem-focused service. Understanding this billing separation helps patients anticipate potential costs that arise when a routine checkup addresses existing or newly discovered medical issues.