CPT Code 99385: Preventive Visit Billing for New Patients 18-39

Key Takeaways

CPT code 99385 covers initial preventive medicine evaluations for new patients aged 18-39 only; use 99395 for established patients in the same age range.

Medicare does not cover CPT 99385 for routine physicals; use AWV codes G0438/G0439 or IPPE G0402 instead.

Same-day E/M visits can be billed alongside CPT 99385 using modifier 25, but only when a separately identifiable medical problem is documented.

ICD-10 codes Z00.00 (without abnormal findings) and Z00.01 (with abnormal findings) are the primary companion codes for 99385 claims.

Commercial payers typically reimburse CPT 99385 at approximately $150-$220, though rates vary by payer, region, and contract year.

Primary care practices bill hundreds of preventive visits every month, yet CPT code 99385 is among the most frequently miscoded in this category. Apply it to an established patient, submit it without the right ICD-10 companion, or confuse it with Medicare’s annual wellness visit structure, and the claim comes back denied. This guide covers everything needed to bill CPT code 99385 accurately: who qualifies, what documentation the visit requires, how to handle same-day E/M services, which ICD-10 codes to pair, and how reimbursement works across different payer types.

The article also covers the full 99381-99387 new patient preventive series and provides a comparison table so practices can quickly select the correct age-based code for every encounter.

CPT Code 99385: Definition, Age Range, and Clinical Scope

CPT code 99385 is defined by the American Medical Association (AMA) as the code for an “initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.” It applies exclusively to new patients between 18 and 39 years of age.

A patient is considered “new” under CPT guidelines if they have not received any professional services from the physician or physician group within the past three years. Once that relationship is established, the correct code shifts to 99395, which covers established patients in the same 18-39 age bracket.

CPT Code 99385 Age Range: The Full New Patient Preventive Series

CPT code 99385 sits within the 99381-99387 new patient preventive medicine series. Each code maps to a specific age band. Using the wrong code for a patient’s age is one of the most common reasons claims in this series are rejected.

The established patient equivalents run 99391-99397, with 99395 covering the 18-39 range. For primary care and GP clinic workflows, having both series mapped in the EHR reduces the chance of selecting the wrong code at checkout.

CPT Code 99385 Documentation Requirements

Missing or incomplete documentation is the leading cause of CPT 99385 claim denials. The AMA’s descriptor specifies that the visit must be “comprehensive,” which means the note needs to demonstrate each component below, not just reference that they occurred.

• Age and gender appropriate history: Social history, family history, past medical history, review of systems relevant to the patient’s age and sex.
• Comprehensive physical examination: Head-to-toe examination appropriate for an 18-39-year-old adult, including blood pressure, BMI, and relevant organ systems.
• Counseling and anticipatory guidance: Documented discussion of risk factors, lifestyle modifications, injury prevention, and safety counseling based on USPSTF recommendations.
• Risk factor reduction interventions: Smoking cessation, substance use screening, sexual health discussion, or other age-appropriate preventive interventions.
• Ordering of laboratory or diagnostic procedures: Documentation of any ordered labs (e.g., lipid panel, STI screening) and the clinical rationale for ordering them.

The note does not need to be lengthy, but every element must appear. A note that documents the physical exam but omits the counseling component will not support a CPT 99385 claim. Claims management software that flags incomplete documentation fields before submission can prevent this category of denial entirely.

CPT Code 99385 Documentation: Counseling Time and Content

Unlike E/M codes where time or MDM drives the level, CPT 99385 is not time-based. The code is selected based on whether the visit was comprehensive and preventive in nature, and whether the patient is new and within the 18-39 age range. That said, the counseling component carries significant weight during payer audits.

The AMA’s CPT coding resources confirm that risk counseling must be documented with specificity. A note stating “lifestyle counseling provided” is insufficient. Practices should document what was discussed, what the patient’s response was, and what follow-up actions were recommended.

ICD-10 Codes Used with CPT Code 99385

Every CPT 99385 claim needs a supporting ICD-10 diagnosis code. The standard options are Z00.00 and Z00.01. Selecting the wrong one, or omitting a secondary code when findings were present, is a frequent source of claim edits.

When Z00.01 is reported, the specific abnormal finding should also appear as an additional diagnosis code on the claim. For example, if elevated blood pressure was discovered, I10 (Essential hypertension) or R03.0 (Elevated blood-pressure reading, without diagnosis of hypertension) would be added depending on whether a formal diagnosis was established. The CDC/NCHS ICD-10-CM web tool is the authoritative source for verifying current code descriptions and validity.

Some payers, including several Medicaid managed care plans, may also accept Z02.89 (Encounter for other administrative examinations) in limited circumstances, but Z00.00 and Z00.01 are the standard codes for commercial preventive visit billing. Confirming payer-specific code requirements through the practice’s claims management workflow before submission avoids unnecessary rework.

CPT Code 99385 and Medicare: What Practices Must Know

Medicare does not cover CPT code 99385 for routine annual physicals. This is one of the highest-risk misunderstandings in preventive medicine billing. Submitting 99385 to Medicare for a beneficiary’s annual preventive visit will result in denial because Medicare’s benefit structure explicitly excludes routine physical examinations under this code series.

Medicare patients have access to separate, specific preventive visit codes:

• G0402 (Welcome to Medicare Preventive Visit / IPPE): For new Medicare beneficiaries within the first 12 months of Part B enrollment.
• G0438 (Annual Wellness Visit, initial): For beneficiaries who have been enrolled in Medicare Part B for more than 12 months and have never had an AWV.
• G0439 (Annual Wellness Visit, subsequent): For beneficiaries who have already had an initial AWV.

As confirmed in the CMS Physician Fee Schedule, CPT 99385 carries a non-covered status under Medicare Part B for preventive services. Practices serving a mixed Medicare and commercial patient population should configure their EHR to flag Medicare patients at check-in so billing staff route them to the correct code set. The right primary care software can automate this routing check and prevent downstream denials.

CPT Code 99385 Same-Day E/M Billing with Modifier 25

A patient comes in for their initial preventive visit and mentions knee pain that has been limiting their mobility for three weeks. The physician examines the knee, orders imaging, and documents a separate assessment and plan for the musculoskeletal complaint. This scenario justifies billing both CPT 99385 and a problem-oriented E/M code on the same date of service.

The rules for same-day billing are specific. Modifier 25 must be appended to the E/M code (not to 99385) to indicate that a separately identifiable evaluation and management service was performed on the same day as the preventive visit. As documented in the AAFP’s January 2022 coding guide, the physician would bill 99385 for the preventive visit and, for example, 99203-25 for the new patient E/M related to the acute knee complaint.

CPT Code 99385 Modifier 25: Documentation Requirements

Three documentation elements must be present for the modifier 25 pairing to survive audit scrutiny:

1. Distinct chief complaint: The medical problem being addressed must be separate from the preventive visit’s scope. Counseling a patient about smoking cessation is part of 99385. Diagnosing and managing a new presenting complaint (knee pain, UTI, skin lesion) is not.
2. Separate documentation: The note must clearly distinguish the preventive visit content from the E/M visit content. Intermingling the two in a single undifferentiated note makes it difficult to defend each service in an audit.
3. Appropriate E/M level selection: The E/M code selected must reflect either the time spent or the medical decision-making complexity for the problem-oriented service alone, not the full encounter.

Payer acceptance of modifier 25 same-day billing varies. Most commercial payers follow AMA guidance, but some have policies requiring pre-authorization or limiting which E/M levels can be billed alongside preventive codes. Checking payer-specific policies before encounter submission, and using a digital documentation workflow that captures both service types as distinct note sections, reduces audit exposure considerably.

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CPT Code 99385 Reimbursement Rates and Payer Considerations

Reimbursement for CPT code 99385 varies by payer, geographic region, and contract year. Based on CMS Physician Fee Schedule data and published fee schedule tools, commercial reimbursement typically falls in the range of approximately $150-$220 per encounter, though this should be treated as an estimate rather than a guarantee. Actual contracted rates depend on individual payer agreements.

Under the Affordable Care Act’s preventive care mandate, commercial insurers are required to cover preventive services recommended with an A or B rating by the USPSTF at no cost-sharing for patients receiving in-network care. Because CPT 99385 represents a comprehensive preventive visit, most ACA-compliant commercial plans cover it fully when billed correctly. However, if the visit triggers additional problem-oriented services billed with modifier 25, the E/M portion may be subject to standard cost-sharing.

CPT Code 99385 vs CPT 99395: Which Code to Use

The distinction is straightforward: 99385 is for new patients aged 18-39, while 99395 is for established patients in the same age range. Billing 99385 for a patient seen within the past three years is one of the most common errors in this code family and triggers automatic claim rejection by most payers.

Both codes carry similar documentation requirements and reimbursement levels, with the key differentiator being patient relationship status. Practices using patient record management software that tracks visit history can surface this distinction at scheduling, eliminating the error before the encounter is ever documented.

Common CPT Code 99385 Billing Errors and How to Avoid Them

Most CPT 99385 denials trace back to a small set of recurring errors. Understanding each one makes them preventable at the workflow level rather than fixable only after denial.

• Wrong patient status: Billing 99385 for an established patient. If the patient has been seen within three years, the correct code is 99395. Check visit history at scheduling, not at billing.
• Age mismatch: Using 99385 for a patient who is 40 or older. The correct code for a new patient aged 40-64 is 99386. Many EHRs can enforce age-based code validation automatically.
• Submitting to Medicare: Medicare does not pay for CPT 99385 as a routine physical. Practices must use G0402, G0438, or G0439 for Medicare beneficiaries receiving preventive care.
• Incomplete documentation: A note that documents the exam but omits counseling, anticipatory guidance, or risk factor interventions will not support a comprehensive preventive visit claim.
• Missing modifier 25 on same-day E/M: When a problem is addressed during the preventive visit, the E/M code must carry modifier 25. Omitting it leads to bundling edits and denial of the E/M service.
• Incorrect ICD-10 selection: Using Z00.00 when abnormal findings were present (should be Z00.01), or failing to add secondary codes for specific abnormal findings identified.

Building these checks into the automated workflow at each stage (scheduling, documentation, charge capture, and submission) is more effective than relying on billing staff to catch errors after the fact. The HIPAA compliance checklist for primary care covers related documentation standards that support clean claim submission across preventive visit codes.

CPT Code 99385 and Telehealth Billing

The expanded telehealth flexibilities introduced during the COVID-19 Public Health Emergency (PHE) allowed preventive medicine services, including CPT 99385, to be billed via telehealth under certain conditions. Following the end of the PHE, telehealth coverage for preventive visit codes has been subject to ongoing Congressional extensions and payer-specific policies rather than a permanent uniform standard.

As of 2025, many commercial payers continue to allow CPT 99385 via telehealth, particularly for audio-visual encounters. However, the comprehensive physical examination component presents a clinical limitation for fully remote visits. Practices billing CPT 99385 via telehealth should verify their specific payer’s coverage policy, confirm the patient is in an eligible originating site location, and document any physical examination components performed or noted as unable to be assessed remotely. Telehealth software that integrates documentation and billing in a single workflow helps ensure these requirements are captured consistently.

Expert Picks: Related CPT Billing Resources

Expert Picks

Need guidance on related preventive care billing codes? Coaching CPT Codes covers wellness and health coaching billing codes used alongside preventive medicine services.

Looking for IVF and reproductive health billing references? IVF CPT Codes covers the procedure codes most relevant to reproductive health billing for patients in the 18-39 age range.

Managing a primary care or GP clinic? GP Clinic Software outlines how Pabau supports preventive visit workflows, documentation, and billing automation for general practice.

Want to reduce claim denials across your billing workflow? Claims Management Software describes Pabau’s tools for automated billing validation and denial prevention.

Conclusion

CPT code 99385 is a high-volume code for primary care practices serving young adult patients, but it is also one of the most frequently miscoded in preventive medicine billing. Applying it to established patients, submitting it to Medicare without understanding the coverage exclusion, or documenting an incomplete preventive note are all patterns that generate denials at scale.

Pabau’s claims management software helps practices build age-based code validation, ICD-10 pairing suggestions, and modifier 25 documentation checkpoints directly into their billing workflow. To see how Pabau handles preventive visit billing from documentation through claim submission, book a demo.

Reviewed against current AMA CPT guidelines and CMS Medicare Physician Fee Schedule guidance for preventive medicine services.

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