CPT 99395 in Medical Billing: Preventive Visit for Ages 18

Preventive services are one of the most important and misunderstood areas of healthcare reimbursement. For many practices, CPT 99395 in Medical Billing becomes a frequent source of claim denials simply because providers, billers, or administrators misunderstand what’s included, what’s not included, and how documentation must be structured.

In 2025, understanding CPT 99395 in medical billing is more important than ever because payers have tightened preventive care rules, and compliance requirements have become stricter. Proper billing helps practices reduce denials, improve revenue cycle performance, and provide patients with cost-free preventive care as allowed under the Affordable Care Act. For medical practices in Florida, partnering with a reputable medical billing company in Florida can ensure accurate coding and smooth reimbursement processes."

I’ve personally worked with multiple family medicine and internal medicine practices over the years, and I’ve seen real situations where a single mistake in preventive documentation or diagnosis coding caused thousands of dollars in lost revenue. One practice I supported had more than 40 claims denied in a single month for preventive visits because staff incorrectly mixed problem-focused elements with routine wellness documentation. Fixing their workflow increased their clean claim rate by 35% within 60 days.

Let’s break everything down clearly, correctly, and in a helpful way.

What Is CPT 99395 in Medical Billing?

Age Range & Preventive Visit Definition

CPT 99395 is used for an established patient preventive visit ages 18–39. It is a routine wellness encounter not a problem-focused visit and it includes a comprehensive age-appropriate history, physical exam, screenings, risk assessment, and counseling.

This preventive visit is different from new-patient E/M codes like CPT 99202 or more detailed new-patient visits such as CPT 99204, which are problem-oriented E/M services.

For adults turning 40 and above, the equivalent preventive visit is documented under CPT 99396, which many practices use alongside adult care protocols.

What Services Are Included?

The CPT 99395 preventive visit includes:

Comprehensive preventive history
Full physical exam
Age-based screening
Health risk assessment
Counseling and anticipatory guidance
Lifestyle, nutrition, and mental health discussion
Preventive care plan for the next year

These are all part of CPT 99395 guidelines and must be clearly documented.

What Is Not Included?

The preventive visit does not cover:

Treatment of acute complaints
Evaluation of chronic disease flare-ups
Office procedures
Vaccines (billed separately)
Labs (billed separately)

If a patient also presents with a problem, that may require a separate E/M code like CPT 99213, CPT 99214, or CPT 99215 depending on the medical decision-making.

Understanding how preventive visits differ from problem-focused services is essential, and is explained more deeply in guides such as the CPT 99213 office visit code, the CPT 99215 high-level visit, and the CPT 99214 physician office visit guide.

Documentation Requirements for CPT 99395

History, Exam & Screening Requirements

To meet CPT 99395 documentation requirements, the following must be clearly included:

Comprehensive preventive history
Age-appropriate physical exam
BMI and vitals
Depression screening
Substance use screening
Immunization status review
Review of chronic condition stability
Family risk factors
Lifestyle counseling

Immunizations, Labs & Add-On Codes

Vaccines are not bundled and should be billed separately using administration codes.
Labs ordered during the visit also bill separately.

For example, if you’re also managing a problem-focused concern, adding CPT 99212 or even a more complex level like CPT 99205 for new patients may be necessary. Lower-level visits such as CPT 99211 remain one of the simplest evaluation codes for minimal services.

When to Use Modifier 25

Modifier 25 is used only when a significant, separately identifiable E/M service occurs alongside the preventive exam.

For example:
A patient scheduled for a preventive exam also reports knee pain requiring problem-focused evaluation. In this case, you may bill:

CPT 99395 (preventive exam)
CPT 99213-25 (problem-focused visit)

Many practices experience CPT 99395 claim denial reasons because they misuse modifier 25 or fail to document the medical necessity for the complaint.

Billing Guidelines for CPT 99395

Payer-Specific Preventive Rules

Each payer has different interpretations of CPT 99395 commercial insurance rules.
Some require yearly frequency; others follow strict 365-day rules.

Medicare does not cover CPT 99395, but Medicare Advantage plans sometimes follow commercial guidelines.

You can review similar preventive coverage scenarios by checking how Medicare Advantage handles adult preventive visits like CPT 99397.

Common Mistakes to Avoid

Using problem-focused diagnosis codes
Missing age criteria
Missing documentation elements
Mixing preventive + acute issues without modifier 25
Incorrect diagnosis sequencing
Using chronic condition ICD codes instead of Z-codes

When CPT 99395 Cannot Be Billed

You cannot bill CPT 99395 when:

The patient is NEW (use CPT 99385, not 99395)
Age is outside 18–39
The visit is purely diagnostic
Only a problem-focused service was performed

Reimbursement for CPT 99395 in 2025

Average Reimbursement Rates

CPT 99395 reimbursement 2025 averages between $140–$190 depending on location, payer, and risk adjustment.

Commercial vs Medicaid vs Medicare

Commercial plans pay the highest
Medicaid pays the lowest
Medicare does not cover this preventive code

CMS preventive guidance for adult preventive exams is structured separately from typical E/M codes like CPT 99201.

Factors Affecting Payment

Reimbursement depends on:

Geographic practice cost index
Documentation completeness
Network status
Z-code accuracy
Whether the patient has had a preventive exam within the year

CPT 99395 vs Typical Office Visit Codes (99213–99215)

Preventive vs Problem-Focused Visit

The preventive exam CPT 99395 is focused on wellness, lifestyle, screening, and anticipatory guidance not symptoms.

Problem-focused codes, such as CPT 99213, CPT 99214, or CPT 99215, are used when evaluating acute or chronic issues.

For more details on problem-focused coding, refer to guides similar to CPT 99203, which explains moderate-complexity E/M services.

When to Bill Both

You can bill both preventive and problem-focused visits if:

A separate complaint is evaluated
Documentation separately supports both
Modifier 25 is used correctly

How to Use Diagnosis Codes Properly

For CPT 99395, primary diagnosis must be:

Z00.00 or Z00.01
(Depending on abnormal findings.)

Secondary diagnosis codes can include:

Screening Z-codes
Chronic condition codes
Risk-factor codes

This ensures correct preventive visit coding for young adults and reduces payer rejections.

Final Summary / Key Takeaways

Correctly billing CPT 99395 in Medical Billing requires:

Proper preventive documentation
correct use of Z-codes
clear separation of preventive vs problem-focused care
correct use of modifier 25
understanding payer-specific rules

To improve your clean claim rate:

Follow CPT 99395 guidelines carefully
Double-check age limits
Never mix problem-focused documentation into preventive exams
Ensure accurate diagnosis coding

If your practice wants help improving compliance, reducing denials, or optimizing preventive visit billing workflows, you can easily schedule a demo with eServMD.

FAQs — CPT 99395 in Medical Billing

1. What is CPT 99395 in medical billing?

CPT 99395 in medical billing refers to a preventive visit for adult patients ages 18–39, covering routine screening, exams, counseling, and preventive care.

2. What documentation is required for CPT 99395?

You must document age-appropriate history, physical exam, screenings, immunizations, and preventive counseling according to payer rules.

3. Can CPT 99395 and 99213 be billed together?

Yes, but only if a separate, medically necessary problem-focused visit occurs. Add modifier 25 to the E/M code.

4. Why do CPT 99395 claims get denied?

Common reasons include incorrect age, missing preventive documentation, billing too soon (frequency limits), or using problem-focused diagnoses only.