CPT Code 99386: Initial Preventive E/M, New Patient, Age 40–64

Learn about the 99386 CPT code for new patients, its requirements, and billing tips to enhance your documentation and coding process.

Use Code

What is CPT code 99386?

CPT code 99386 is used for a comprehensive preventive medicine evaluation and management service for a new patient between the ages of 40 and 64. This code encompasses a complete evaluation focused on age—and gender-appropriate history, examination, counseling, risk factor reduction, and the ordering of appropriate immunizations, laboratory, and diagnostic screening tests.

Unlike problem-oriented services, preventive medicine visits concentrate on health maintenance and disease prevention rather than addressing specific illnesses or complaints. The 99386 CPT code is designed specifically for new patients who have not received professional services from the physician or another healthcare professional of the same specialty in the same group practice within the past three years.

The comprehensive preventive medicine evaluation covered by code 99386 serves multiple purposes in health care:

Early detection of potential health issues before they become serious conditions
Assessment and management of risk factors for various diseases, particularly cardiovascular disease
Provision of age-appropriate counseling and anticipatory guidance
Development of personalized prevention strategies based on the patient's medical history and risk profile
Administration or ordering of recommended immunizations and screening tests

The U.S. Preventive Services Task Force (USPSTF) considers preventive services as crucial for reducing morbidity and mortality across the population. For adults aged 40-64, these services can be particularly impactful in addressing conditions like cardiovascular disease, diabetes, and certain cancers that become more prevalent in middle age.

CPT code 99386 documentation requirements

Proper documentation is essential when reporting CPT code 99386, as it substantiates the comprehensive nature of the preventive visit and supports medical necessity. Documentation should reflect the depth and breadth of the preventive evaluation provided.

Comprehensive history

Documentation should include a comprehensive assessment of the patient's medical history, including:

Complete review of past medical history
Detailed family history, particularly focusing on conditions with genetic components
Social history, including lifestyle factors such as tobacco use, alcohol consumption, diet, and exercise habits
Review of body systems relevant to the patient's age and risk factors

Comprehensive physical examination

The physical examination for a 99386 service should be multi-system and age/gender-appropriate. Documentation should reflect:

Vital signs (blood pressure, pulse, respiration, temperature, height, weight, BMI)
Head-to-toe physical assessment
Age-appropriate examinations (e.g., breast examination, testicular examination)
Focused evaluation of systems with identified risk factors

Assessment and plan

Documentation should include:

Assessment of the patient's overall health status
Identification and assessment of risk factors
Age-appropriate counseling and anticipatory guidance provided
Risk factor reduction interventions discussed
Recommendations for screening tests and immunizations
Plan for follow-up visits or additional testing as appropriate

CPT code 99386 billing guidelines

Understanding the proper billing guidelines for CPT code 99386 is crucial for healthcare providers to ensure appropriate reimbursement while maintaining compliance with payer requirements.

The Affordable Care Act significantly expanded coverage for preventive services, requiring many health plans to cover preventive medicine services without cost-sharing. However, coverage policies can vary:

Medicare does not typically cover the comprehensive preventive medicine CPT codes (including 99386), but instead uses annual wellness visit (AWV) codes (G0438 for initial AWV).
Many commercial payers cover preventive medicine services, but may have specific frequency limitations.
Medicaid services coverage varies by state.

Healthcare providers should verify coverage policies with specific payers before providing services to ensure patients understand potential financial responsibilities.

A common billing challenge occurs when a patient presents for a preventive visit but also has concerns about a specific problem that requires additional work beyond the scope of the preventive service. In these cases:

The preventive medicine service (99386) can be reported
If a separately identifiable evaluation and management service is provided, it can be reported with the appropriate problem-oriented E/M code with modifier -25
Documentation must clearly delineate the elements of both services

Frequently asked questions

CPT code 99396 is used for a comprehensive preventive medicine evaluation and management service provided to established patients aged 40 to 64 years. It covers an annual wellness visit that includes detailed medical history, comprehensive physical examination, counseling, screenings, and risk assessment tailored to this age group to promote disease prevention and health maintenance.

Medicare generally covers preventive services like annual wellness visits. Still, CPT code 99386, for new patients aged 40-64, may have specific coverage criteria depending on the Medicare plan and should be verified with the payer.

CPT codes 99386 and 99204 cannot typically be billed together for the same encounter because 99386 is a preventive medicine service for new patients, while 99204 is an evaluation and management code for new patient office visits with a problem focus; billing both without proper modifiers or distinct services risks claim denial due to overlapping services.