CPT Code 99394: Adolescent Preventive Medicine, Established Patient (Age 12–17)

What is CPT code 99394?

CPT code 99394 is used for the preventive medicine evaluation of adolescents aged 12 to 17 years who are established patients. The visit includes:

• A comprehensive history (medical, psychosocial, and family history) relevant to the age and gender appropriate development of the adolescent.
• A thorough examination, counseling, and anticipatory guidance that addresses health concerns, such as risk factor reduction interventions, including alcohol abuse and dependence, or substance abuse, structured, e.g., an audit.
• Counseling anticipatory guidance risk on nutrition, mental health, and guidance risk factor reduction, ensuring that the adolescent understands the importance of anticipatory guidance risk factor reduction for their overall well-being.
• A review of immunizations, as well as screenings for common conditions like depression, STI risk, and fetal alcohol spectrum disorders.

This preventive visit is an opportunity for risk factor reduction strategies to be discussed and implemented, focusing on substance abuse, structured, eg, such as addressing alcohol use abuse and alcohol spectrum disorders program.

Documentation requirements

For accurate billing and to meet the documentation requirements for CPT code 99394, the following elements must be thoroughly documented:

Comprehensive history

Include a detailed history examination and counseling that anticipates the medical, psychosocial, and family history of the adolescent, ensuring that age- and gender appropriate history examination details are captured. The history should also address relevant risk factor reduction interventions, including but not limited to substance abuse structured eg audit, alcohol use abuse, and the possibility of any alcohol and/or substance abuse concerns, tailored to the adolescent's age group. This will ensure proper context for understanding potential risks and providing appropriate history for preventive care.

Complete physical examination

Conduct a thorough physical exam with attention to age and gender appropriate evaluations. This should include counseling, anticipatory guidance, and risk for specific health topics like nutrition, mental health, and physical development. The examination should address any potential signs of alcohol abuse and dependence, substance abuse, structured eg, or mental health issues that could impact the adolescent’s well-being, guiding further risk factor reduction strategies.

Counseling

Provide comprehensive counseling, anticipatory guidance, and risk assessment on various health behaviors, with particular focus on alcohol use and abuse, substance abuse, structured eg audit, and mental health concerns. This counseling should be geared toward promoting positive behaviors, enhancing awareness of the alcohol spectrum disorders program, and providing guidance on fetal alcohol spectrum disorders prevention and treatment. It is essential to discuss alcohol abuse counseling and ensure that alcohol abuse and dependence are addressed effectively as part of the preventive medicine evaluation.

Review

Discuss the adolescent’s vaccines, safety topics, and strategies for reducing risk factors related to anticipatory guidance. This includes reviewing any alcohol and/or substance abuse screenings, presumptive drug tests, and the adolescent’s readiness for fetal alcohol spectrum disorders screenings. Additionally, make sure to provide clear anticipatory guidance on substance abuse, structured education, and alcohol use abuse, along with other preventive medicine services such as advice on nutrition, injury prevention, and mental health support.

Billing guidelines

Below are the key billing guidelines for CPT code 99394:

• Frequency of billing: Bill CPT code 99394 once per calendar year unless the payer allows additional visits. It is important to check payer guidelines to confirm the frequency.
• Modifier -25 usage: Do not report CPT 99394 in conjunction with a problem-oriented E/M service unless the services are distinct and separately documented. In such cases, apply modifier -25 to indicate that the preventive medicine evaluation and management service was provided separately from the problem-focused encounter.
• Vaccinations and lab screenings: Any vaccinations and laboratory diagnostic procedures (such as drug tests or screening for alcohol use abuse or substance abuse, structured, eg, audit) must be billed separately using the appropriate CPT codes. Ensure that these services are properly documented and coded in accordance with payer requirements.
• Validation: Be sure that sample validation, when performed for any diagnostic procedures (e.g., drug tests presumptive), is clearly documented. This ensures accurate billing and compliance with payer guidelines for preventive services.
• ICD diagnosis codes: Always include relevant ICD diagnosis codes to support the preventive visit, such as codes for alcohol abuse, substance abuse, or any other condition that is part of the preventive evaluation. Ensure that the diagnosis codes match the services documented during the visit.