Preventive care visits play a vital role in keeping adult patients healthy and helping providers receive timely reimbursements. Among the preventive medicine codes, CPT 99396 in medical billing stands out as one of the most commonly used for adult preventive visits.
As a medical billing specialist, I’ve seen how CPT 99396 can be confusing for providers especially when mixed with problem-oriented visits or when documentation isn’t clear enough for payers. Let’s explore how to use this code accurately and maximize reimbursement while staying compliant.
What Is CPT 99396?
CPT 99396 in medical billing represents a periodic preventive medicine reevaluation for established adult patients aged 40–64 years.
This code covers a comprehensive preventive health exam that includes reviewing medical history, performing a physical exam, and providing counseling about risk factors and preventive care.
Unlike problem-focused visits (such as CPT 99213), CPT 99396 does not address acute conditions or chronic disease management. Instead, it focuses solely on preventive care like blood pressure monitoring, vaccination updates, and age-appropriate screenings.
When to Use CPT 99396
This code is used when a patient comes in for a routine annual or preventive checkup, not because of illness or symptoms. For instance, a 50-year-old established patient visiting their doctor for an annual wellness exam would fall under CPT 99396.
Common real-world examples include:
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Annual physicals for middle-aged adults.
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Preventive visits with lifestyle or diet counseling.
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Screenings for hypertension, diabetes, or cholesterol.
However, if a patient also discusses a specific medical problem during the same visit, such as knee pain or medication management, you’ll need to bill an additional E/M code (like CPT 99212) with a modifier -25 to indicate a separate, significant service.
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Documentation Requirements for CPT 99396
The CPT 99396 documentation requirements are clear but often misunderstood. Payers require comprehensive and age-appropriate preventive documentation, including:
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Updated patient history and risk factors
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Physical exam results
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Lifestyle and behavioral counseling
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Screenings and preventive service notes
From my experience working with clinics, most denials for CPT 99396 reimbursement occur due to incomplete documentation. For example, one family medicine practice I worked with was repeatedly underpaid until we noticed missing counseling notes in their templates. Once they updated their EHR documentation, their acceptance rate for preventive visit claims improved by 30%.
If you’re unsure about documentation standards, partnering with experts like eServMD’s medical coding team ensures every preventive visit is coded accurately.
CPT 99396 Reimbursement and Payer Policies
Reimbursement for CPT 99396 in medical billing varies based on payer, region, and contractual rates. Medicare typically does not cover CPT 99396, as it uses different preventive visit codes (like G0439 for annual wellness visits).
However, most private insurance plans including Aetna, Cigna, and UnitedHealthcare reimburse CPT 99396 under preventive services if the patient meets age and frequency criteria.
Here’s what to remember:
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Always verify the patient’s preventive benefits and coverage frequency before billing.
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Use accurate diagnosis codes (Z00.00 or Z00.01) for preventive exams.
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For better payer compliance, follow the 99396 reimbursement guidelines from each insurer.
If you struggle with payer-specific coding variations, Revenue Cycle Management (RCM) services can simplify verification and prevent claim denials before submission.
🔗 CPT 99205 in Medical Billing: High-Complexity New Patient Visit
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Common Mistakes in Billing CPT 99396
Many providers mistakenly combine preventive and problem-oriented visits under CPT 99396, which leads to denials or compliance risks. Here are frequent issues:
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Using CPT 99396 for patients outside the 40–64 age range.
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Missing separate documentation for additional problem visits.
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Failing to use the correct modifier -25.
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Billing CPT 99396 with non-preventive ICD-10 codes.
In one real-world case, a clinic billed CPT 99396 and 99213 together without modifier -25. The payer rejected all 45 claims, delaying over $8,000 in reimbursements. Once we corrected the billing approach and re-trained staff on documentation, the denial rate dropped dramatically.
If your team faces similar issues, consider professional help through Practice Management Consulting to enhance compliance and efficiency.
CPT 99396 vs 99397: What’s the Difference?
Providers often confuse 99396 vs 99397, but the difference lies in patient age.
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CPT 99396 – Established patients aged 40–64
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CPT 99397 – Established patients aged 65 and older
For example, if a 67-year-old comes in for a preventive exam, the correct code is CPT 99397, not 99396. Using the wrong code can trigger denials and compliance audits.
🔗 CPT 99215 in Medical Billing: High-Level Office Visit Code
Best Practices for Accurate CPT 99396 Billing
To ensure accurate preventive visit billing for adults, follow these best practices:
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Confirm patient eligibility before scheduling preventive visits.
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Document all preventive counseling and screening recommendations.
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Avoid mixing problem-oriented visits unless clearly justified and documented.
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Use correct diagnosis codes that match preventive purposes.
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Stay updated with payer-specific 99396 reimbursement guidelines and policy changes.
If your billing workflow still faces issues, tools like eServMD’s Medical Billing Services can automate eligibility checks and minimize denials.
Real-Life Experience: How One Clinic Improved Preventive Visit Billing
At one of the family practices I worked with in 2024, the clinic’s preventive care billing success rate was only 72%. Most denials cited missing documentation for counseling and risk discussions crucial for CPT 99396 in medical billing.
We conducted a full audit, updated their documentation templates, and integrated automatic eligibility verification through a new EHR system. Within three months, reimbursement improved to 96%, and claims for CPT 99396 were paid faster and with fewer follow-ups.
This small change not only reduced administrative burden but also increased patient satisfaction because preventive visits became smoother and more transparent.
Before You Code: What to Remember About CPT 99396
Preventive medicine visits are the foundation of proactive healthcare and CPT 99396 in medical billing ensures providers are reimbursed fairly for their efforts.
Accurate coding, clear documentation, and timely verification can prevent denials and improve patient outcomes. By working with experts like eServMD, clinics can stay compliant, increase revenue, and focus more on patient care than paperwork.
If you’re looking to simplify preventive visit billing or want to see how automation can improve your workflow, schedule a demo with eServMD today and experience seamless medical billing efficiency.
