CPT® Code 99396 is used to report a comprehensive preventive medicine evaluation and management (E/M) service for an established patient aged 40 to 64 years. This service includes a detailed history and physical examination as well as counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of appropriate immunizations and laboratory/diagnostic procedures tailored to the patient’s age and health status.
This code is used during routine health maintenance visits, commonly known as annual or physical exams, when the patient is already established with the practice and the purpose of the visit is preventive—not problem-based.
Key facts about CPT Code 99396
- Service type: Preventive (not problem-oriented)
- Patient type: Established, ages 40–64
- Includes:
- Full history and physical exam
- Review of age/gender-specific risk factors
- Screening and counseling (e.g., cardiovascular, metabolic, mental health, cancer prevention)
- Review and recommendation of immunizations and diagnostic screenings
- Does not include:
- Management of new or existing problems (which require additional E/M codes if addressed)
When to use CPT Code 99396
CPT 99396 should be used when an established adult patient aged 40 to 64 presents for a preventive exam, with no acute concerns as the primary reason for the visit. The encounter focuses on proactive wellness and risk reduction through screening, education, and early intervention.
If a significant new problem or chronic condition is evaluated during the visit, a separate problem-focused E/M code (e.g., 99214) may be billed with modifier -25, as long as it is properly documented.
Documentation requirements
To bill CPT 99396 correctly and ensure compliance, documentation should include:
- A complete medical, family, and social history (updated annually)
- A comprehensive physical examination appropriate to the patient’s age and gender
- Screening and counseling on:
- Cardiovascular risk factors (e.g., blood pressure, lipids)
- Cancer screenings (e.g., colonoscopy, mammography, Pap smear)
- Mental health and substance use
- Lifestyle habits (e.g., diet, exercise, sleep, stress)
- Sexual and reproductive health
- Orders for laboratory tests and immunizations, if applicable
Reimbursement and coding considerations
CPT 99396 is typically covered by commercial insurers as part of preventive care benefits, especially under ACA-compliant plans, often without patient cost-sharing. However, reimbursement policies vary, so practices should:
- Verify preventive care coverage before the visit
- Use appropriate ICD-10 codes (e.g., Z00.00 or Z00.01)
- Avoid bundling unrelated services unless separately documented
- Clearly distinguish preventive vs. problem-focused care in the note if both are performed
Medicare does not reimburse 99396; instead, it covers Annual Wellness Visits using different G-codes (e.g., G0439).
How OptiMantra supports streamlined preventive care documentation
OptiMantra’s fully integrated EHR and practice management platform is designed to help wellness- and prevention-focused clinics document and bill preventive visits like CPT 99396 with ease and accuracy. With OptiMantra, providers can:
- Use customizable visit templates tailored for preventive services by age and gender
- Automatically prompt for required history, screenings, and counseling elements
- Track immunizations, lab results, and screening timelines within the patient chart
- Generate accurate billing claims with suggested CPT and ICD-10 codes
- Document additional E/M services during the visit with modifier support built in
For practices delivering whole-person, preventive care, OptiMantra ensures that every aspect of the visit—from intake to documentation to billing—is optimized for both compliance and efficiency.
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