CPT Code 99386: New Patient Preventive Visit Guide

Key takeaways

CPT Code 99386 covers the initial comprehensive preventive medicine evaluation for new patients aged 40 to 64.

The note must document history, physical exam, counseling, risk factor reduction, and any lab orders.

The AMA counts a patient as new when no same-specialty physician in that group has seen them for three years.

Medicare Part B does not cover CPT 99386. Use G0438 or G0439 for the Annual Wellness Visit, and G0402 for the Welcome to Medicare exam.

Practice management software like Pabau checks eligibility, submits 99386 claims, and tracks denials in one workflow.

CPT Code 99386 is the billing code for a new patient comprehensive preventive medicine evaluation, ages 40 to 64. It sits in the American Medical Association’s preventive medicine series (99381-99397). Primary care and internal medicine bill it more than almost any other code in that series.

Three inputs decide whether a 99386 claim pays: the patient’s status, the primary diagnosis, and the payer. Traditional Medicare Part B does not cover the code at all, so a Medicare patient needs a G-code instead. All three inputs are knowable before the visit starts.

CPT Code 99386 at a glance

The American Medical Association (AMA) descriptor for CPT Code 99386 begins: “Initial comprehensive preventive medicine evaluation and management of an individual.” It continues: “including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions.” It closes: “and the ordering of laboratory/diagnostic procedures, new patient, 40-64 years.”

Three elements of that descriptor matter most for billing. First, “initial” means this is a new patient visit. Second, the evaluation must be “comprehensive,” covering history, physical, and counseling in full. Third, “ordering of laboratory/diagnostic procedures” is listed as part of the code’s scope. The AMA clarifies that ordering is required only when clinically indicated, not for every visit.

Age and patient status rules

Two eligibility conditions must both be true before billing CPT Code 99386. The patient must be aged 40 to 64 on the date of the visit. They must also qualify as a new patient under the AMA’s definition.

The AMA defines a new patient through a three-year look-back. The patient must not have received any face-to-face professional service from the physician in that window. The same test applies to another physician of the same specialty and subspecialty in that group practice. So a patient who saw a different internist at the same group eight years ago, then left, qualifies as new again.

• Patient age: Must be between 40 and 64 on the date of service. A 65-year-old does not qualify. Use 99387 for patients aged 65 and older.
• New patient status: No face-to-face visit with any same-specialty physician in the same group within the past three years.
• Patient type clarification: Telehealth visits may count toward the three-year look-back, depending on payer policy. Confirm this with each commercial carrier.
• Payer variation: Some payers apply group NPI rules differently. A patient transferred from a retiring partner within the same TIN may still be treated as established by certain insurers.

What the preventive visit must include

The AMA descriptor is specific about what the visit must encompass. Each component below must be documented. Missing even one opens the claim to a medical necessity denial.

• Age and gender appropriate history: Chief complaint, past medical history, family history, and social history. Add a review of systems relevant to the patient’s age and sex.
• Comprehensive physical examination: A multi-system exam appropriate for a 40-64-year-old patient, including cardiovascular, respiratory, musculoskeletal, and other relevant systems.
• Counseling and anticipatory guidance: Documented discussion of age-appropriate risk factors such as cardiovascular disease, cancer screening, tobacco use, alcohol use, weight, and exercise.
• Risk factor reduction interventions: Active recommendations or referrals based on identified risk factors. These must be recorded, not just implied.
• Ordering of laboratory or diagnostic procedures: When clinically indicated, orders for screening labs (lipid panel, fasting glucose, CBC, etc.) or diagnostic imaging. Ordering is not required when not clinically indicated, but must be considered and documented.

Documentation the chart note has to carry

Documentation failure is the leading cause of 99386 denials on post-payment audit. The chart note must support every component of the visit on its face, without the auditor having to infer what happened.

A well-structured note carries a billing trail that matches the encounter, a discrete counseling section, and a review of systems written for this patient. Copying a generic review of systems from a prior visit invites a refund demand. It is one of the most common triggers on a RAC or MAC audit.

• Chief complaint: Even preventive visits need a brief statement of patient intent (“here for annual physical exam”).
• Comprehensive history: Past medical history, surgical history, family history, social history, and a multi-system review of systems.
• Physical exam: At minimum, document all body systems examined and findings. Abnormal findings must be described specifically.
• Counseling note: List the specific topics discussed (e.g., “counseled patient on cardiovascular risk, discussed statin therapy options, reviewed cancer screening schedule”). Generic phrases like “counseling provided” are insufficient.
• Risk factor reduction: Document specific recommendations made and whether the patient accepted, declined, or was referred.
• Lab orders: When labs are ordered, list them with the clinical indication and any patient education about how results are returned.

ICD-10 diagnosis codes that pair with 99386

Selecting the wrong primary diagnosis is a fast path to a denied claim. Preventive visits must lead with a Z-code. A symptom-based or chronic condition code in the primary position converts the claim from preventive to problem-focused. That triggers different coverage rules, and often a denial.

Secondary chronic condition codes (hypertension, diabetes, hyperlipidemia) may be added when those conditions are assessed or managed during the same encounter. They must never appear as the primary diagnosis on a 99386 claim. Screening and family-history Z-codes run deeper than the five rows above, and the ICD-10-CM code index lists the rest by subcategory.

Reimbursement rates and fee schedule in 2025

The 2025 Medicare Physician Fee Schedule does not reimburse CPT 99386 under traditional Medicare Part B. The Medicare section below explains why. For commercial payers, reimbursement is negotiated contract by contract, and it varies by region and plan type. The figures below are national estimates from available 2025 fee schedule data. Verify current rates with the CMS Physician Fee Schedule lookup tool, your MAC, and your carrier contracts.

Practices that submit electronically through a clearinghouse can confirm payer-specific rates and eligibility in real time, before the patient arrives. That is where most billing surprises get caught.

Medicare and Medicaid coverage

Traditional Medicare Part B does not cover CPT Code 99386. This is one of the most frequently misunderstood facts in preventive medicine billing. Billing 99386 to a traditional Medicare patient will result in a denial because the code is not on the CMS covered preventive services list. Instead, Medicare has created dedicated wellness visit codes that cover comparable services.

• G0402 (Welcome to Medicare Physical): A one-time preventive visit for new Medicare enrollees within the first 12 months of Part B coverage. Covers history, physical, and referrals but is more limited in scope than 99386.
• G0438 (Annual Wellness Visit, initial): The first AWV for an established Medicare beneficiary. This is not a head-to-toe physical. It focuses on health risk assessment, a prevention plan, and cognitive evaluation.
• G0439 (Annual Wellness Visit, subsequent): Used for all AWVs after the first. Same structure as G0438 but for returning Medicare patients.

Checking eligibility before a preventive visit prevents the common error of billing 99386 against a plan that will not cover it. Some Medicare Advantage plans do cover 99386 through their supplemental benefit structure. That is plan-specific, so verify it individually.

Medicaid coverage of 99386 varies by state. Many state Medicaid programs cover preventive medicine services for adults, but fee schedules and frequency limits differ significantly. Check your state Medicaid agency’s published fee schedule for the current rate and any prior authorization requirements.

CPT 99386 vs 99396: new patient vs established patient

The most common code selection error in the preventive medicine series is swapping 99386 and 99396. Both cover adults aged 40 to 64. Patient status is the only distinction. Getting it wrong produces a denial, and a repeating error pattern becomes a compliance problem.

Age band, payer, and patient status settle the code between them, and the order matters. The path below runs those three checks in the order that fails a claim fastest.

Related preventive medicine CPT codes

CPT 99386 is one code in a series of 14 preventive medicine codes covering patients from infancy through age 65 and older. The series splits into new patients (99381-99387) and established patients (99391-99397). Knowing where 99386 sits prevents age-band errors when a patient moves from one band to the next.

Practices that also bill preventive counseling add-on codes (99401-99404) can report those separately when counseling is the exclusive purpose of a visit. For most payers, the National Correct Coding Initiative (NCCI) edits do not bundle them into 99386.

Billing a same-day E/M service with modifier 25

Modifier 25 is the mechanism for billing a separate evaluation and management service on the same day as a preventive medicine visit. It is also one of the most frequently misused modifiers in primary care, and one of the Office of Inspector General’s documented audit targets.

The rule works like this. A patient presents for a preventive visit, and the physician finds a new problem needing significant work beyond the preventive exam. That extra evaluation and management service can be billed with modifier 25 appended. The two services have to be documented separately in the chart.

A worked example makes the split clear. A 52-year-old new patient arrives for her first annual physical. The physician records blood pressure readings consistent with hypertension, runs a focused cardiovascular assessment beyond the routine exam, and starts a treatment plan.

The preventive visit is billed as 99386. The hypertension evaluation carries its own focused history, assessment, and plan, so it is billed as 99213 or 99214 with modifier 25. The chart needs two distinct documentation sections, written separately.

• The E/M must be significant and separately identifiable: Routine counseling within the scope of the preventive visit does not qualify. The problem must require additional work beyond what is inherent to the preventive exam.
• Document separately: The chart note must clearly separate the preventive visit from the E/M service. Combining them into one narrative is the most common audit trigger.
• Not all payers accept modifier 25 here: Some commercial plans restrict same-day E/M billing with preventive codes, and some state Medicaid programs do too. Verify before billing.
• OIG audit risk: Consistent high rates of 99386 billed with modifier 25 attract scrutiny. The pattern should reflect genuine clinical need, not a billing template.

Common billing errors and claim denials

Most 99386 denials fall into one of six categories. Practices that track denial reason codes systematically can see which error pattern dominates. Fixing that root cause once beats working each rejected claim by hand.

• Wrong patient status: Billing 99386 for an established patient. The fix is a front-desk eligibility and status check at scheduling, not at billing.
• Missing documentation components: Counseling notes that say “counseling provided” without specifying topics discussed. Auditors and payers look for specificity.
• Incorrect primary ICD-10 code: Using a chronic condition code (E11.9, I10) as primary instead of Z00.00 or Z00.01. This reframes the claim as problem-focused, not preventive.
• Medicare billing error: Submitting 99386 to traditional Medicare Part B. The denial is automatic. The solution is a reliable eligibility verification step that flags Medicare patients before the claim is submitted.
• Bundling conflicts: Billing 99386 alongside services that NCCI edits bundle into the preventive visit. Check NCCI edits for any additional codes billed on the same day before submission.
• Modifier 25 without supporting documentation: Appending modifier 25 to an E/M without a clearly separated note section. This is correctable at the point of documentation, not at billing.

Practices running high volumes of preventive visits can structure their own internal audits around these six categories. Finding the pattern yourself is cheaper than having a MAC or a commercial payer find it.

How Pabau supports 99386 billing and documentation

The requirements for 99386 create two workflow problems for a primary care practice. The chart note has to capture every required component before the patient leaves. The claim then has to go out with the right code, the right ICD-10 pairing, and the right modifier logic.

Practice management software like Pabau works on both. Digital intake forms and structured note templates can be set up to prompt clinicians for each required element. That covers history, review of systems, exam findings, counseling topics, and lab orders. A note that is complete at the point of care produces a cleaner claim downstream.

On the billing side, cleaner claims management starts with a real-time eligibility check before the visit. Claim submission and remittance tracking follow it. Denials surface in the system instead of aging in a queue.

99386 denials are preventable at each of those steps. Eligibility gets checked before the visit, the note gets structured during it, and the claim goes out clean afterward. Running the three steps in one system is what stops any of them from being skipped on a busy morning.

Stop losing preventive visit revenue to billing errors

Pabau’s practice management platform integrates with Claim.MD to automate eligibility checks, streamline 99386 claim submission, and flag denial patterns before they repeat. See how primary care and internal medicine practices keep more of every preventive visit.

Book a demo

Conclusion

Run the three checks at scheduling, not at billing. Patient status, payer, and primary diagnosis are all knowable before the patient sits down. All three are expensive to correct once a claim has been denied.

That moves work forward onto the front desk, which is the trade-off worth naming. A practice willing to take it stops writing off preventive visits that were documented properly and coded wrong.

To see how Pabau verifies eligibility, submits 99386 claims, and tracks denials in one place, book a demo.

Continue your research

Want a structured framework for preventive billing compliance? Medical billing compliance practices covers audit-readiness, RAC preparation, and internal review processes for primary care billing teams.

Need to understand how clearinghouse claim submission works? Revenue cycle management fundamentals explains the end-to-end flow from eligibility check to remittance posting.

Looking for denial management guidance? Denial codes in medical billing breaks down the most common reason codes and how to respond to each one.

Want to catch a non-covered preventive benefit before the visit? Insurance eligibility verification walks through the checks that flag a Medicare patient at scheduling.

Billing a preventive visit for a patient over 64? CPT Code 99387 covers the same initial comprehensive evaluation for new patients aged 65 and older.

Frequently asked questions