CPT® Code 99395 is used to report a comprehensive preventive medicine evaluation and management (E/M) service provided to an established patient aged 18 to 39 years. This code represents a routine adult physical exam, focused on screening, counseling, and preventive health maintenance—rather than evaluation of new or existing problems.
This code is used when a young adult patient returns for their annual physical or wellness visit, and the primary focus is prevention and risk reduction.
Key facts about CPT Code 99395
- Service type: Preventive (non-problem focused)
- Patient type: Established, age 18–39
- Includes:
- Comprehensive history and physical exam
- Review of health risks by age, gender, and lifestyle
- Screening for physical, mental, and behavioral health
- Preventive counseling (e.g., nutrition, activity, contraception)
- Orders for age-appropriate immunizations and labs
- Excludes:
- Evaluation or management of specific symptoms or conditions (requires additional E/M coding)
When to use CPT Code 99395
CPT 99395 should be billed when an adult patient aged 18–39 presents for a preventive check-up with no acute or chronic condition management as the primary reason for the visit. This service supports early detection, patient education, and long-term health planning.
If a new health issue or chronic condition is addressed significantly during the same visit, a problem-based E/M code (e.g., 99213) can also be billed with modifier -25, provided the documentation clearly separates the services.
Documentation requirements
To ensure accurate coding and audit protection, the medical record should reflect:
- A full medical, family, and social history (updated annually)
- A detailed physical exam based on age, gender, and individual risk
- Counseling and anticipatory guidance on:
- Lifestyle and behavioral health (e.g., diet, exercise, substance use)
- Reproductive and sexual health
- Injury prevention, mental health, and chronic disease risk
- Immunizations administered or recommended
- Preventive screenings ordered (e.g., STI, cholesterol, cervical cancer)
The documentation should clearly indicate that the service was preventive in nature, and not performed to address existing conditions.
Reimbursement and coding considerations
Most commercial payers cover CPT 99395 under preventive care benefits, especially for ACA-compliant plans that support routine wellness visits without cost-sharing. However, coverage can vary by payer and policy.
Consider the following:
- Use preventive ICD-10 codes like Z00.00 or Z00.01
- Confirm the patient’s eligibility for annual preventive services
- Do not include significant problem-based care unless separately documented
- Medicare does not cover 99395; instead, it covers Annual Wellness Visits (G0438/G0439)
How OptiMantra enhances preventive visit workflows
For wellness, integrative, and primary care providers, OptiMantra makes it easy to deliver, document, and bill CPT 99395 services with confidence. The platform includes:
- Pre-built and customizable templates for age-appropriate preventive visits
- Smart intake forms that collect relevant patient history in advance
- Automated prompts for recommended screenings and vaccinations
- Seamless billing tools that flag preventive codes and support correct modifier use
- Patient portal tools for ongoing health engagement between annual visits
Whether you're focused on conventional care or functional wellness, OptiMantra ensures that your preventive visits are comprehensive, compliant, and reimbursable—without slowing you down.
Try OptiMantra for free here!
