CPT Code 99396: Preventive Medicine Visit (Established Patient)

What is the CPT code 99396?

CPT code 99396 is used for reporting healthcare services, specifically a comprehensive preventive medicine evaluation and management service for established patients between 40 and 64 years of age. Unlike problem-oriented visits, this preventive services code encompasses a thorough assessment of the patient's overall health status aimed at disease prevention and early identification of potential health concerns.

Preventive medicine services involve a thorough assessment and management of a person, which includes an age- and gender-appropriate medical history, physical examination, counseling or guidance, interventions for reducing risk factors, and the request for laboratory or diagnostic tests.

CPT code 99396 documentation requirements

A comprehensive preventive medicine evaluation under CPT code 99396 consists of several essential components for proper medical billing services and accurate and detailed documentation:

• Comprehensive medical history: Healthcare providers must gather a detailed medical history, including past illnesses, surgeries, medications, allergies, and a family history of diseases that might impact the patient's health status.
• Comprehensive physical examination: The preventive visit should include an age-appropriate examination that includes vital signs, a review of body systems, and screening services based on the patient's age and specific risk factors. The physical examination findings must also be properly reported and stored.
• Risk assessment: Identifying potential risk factors based on the patient's lifestyle, family history, and other health determinants that might require timely intervention.
• Counseling services provided: Age-appropriate guidance on diet, exercise, substance use, mental health, and other relevant health topics designed to support disease prevention.
• Personalized preventive medicine planning: Proper preventive care involves developing recommendations for screenings, immunizations, and lifestyle modifications tailored to each patient.

Distinguishing preventive from problem-oriented services

To ensure accurate billing and accurate documentation, primary care providers must distinguish between preventive medicine evaluations and problem-oriented visits. While a preventive medicine visit focuses on maintaining health and preventing disease, problem-oriented visits address specific complaints or manage existing conditions. This distinction is crucial for accurate medical billing and appropriate reimbursement.

CPT code 99396 billing guidelines

Healthcare providers must follow specific billing guidelines when using CPT code 99396 to ensure accurate billing and maximize reimbursement for preventive medicine services.

Basic billing principles

The comprehensive preventive medicine evaluation must be the primary focus of the encounter. The documentation must support the comprehensive nature of the service, and the patient's age must be verified to confirm the appropriate code selection. The service must be provided to an established patient.

Common billing scenarios

The common billing scenarios in using these comprehensive preventive services include the following:

• Preventive service only: CPT code 99396 should be reported without additional codes when only a preventive medicine evaluation is performed.
• Preventive service with problem-oriented service: When a significant, separately identifiable problem-oriented evaluation and management service is provided during the same encounter, both the preventive medicine code (99396) and the appropriate problem-oriented E/M code may be reported with modifier -25 appended to the problem-oriented code.
• Preventive service with additional procedures: When specific procedures (e.g., immunizations, lab tests) to address and identify potential health concerns are performed in addition to the preventive medicine evaluation, these services should be reported separately.

Accurate coding is essential to ensure compliance with billing requirements and support medical necessity.

Ensuring accurate medical billing

Primary care providers and medical billing professionals should implement these practices to ensure accurate billing:

• Thorough documentation: Maintain comprehensive records of all services provided during the preventive visit.
• Code verification: Verify that CPT code 99396 is appropriate based on the patient's age and established status.
• Modifier usage: Apply appropriate modifiers when additional services are provided during the same encounter.
• Medical necessity: Ensure documentation supports the medical necessity of all services rendered.

Other relevant codes

When providing preventive medicine services, healthcare providers should be familiar with related CPT codes that might be relevant:

• 99385: Initial preventive medicine evaluation (new patient; 18-39 years)
• 99386: Initial preventive medicine evaluation (new patient; 40-64 years)
• 99387: Initial preventive medicine evaluation (new patient; 65+ years)
• 99395: Established patient preventive medicine (18-39 years)
• 99397: Established patient preventive medicine (65+ years)