CPT Code 99387: Preventive Visit, New Patient 65+

Key Takeaways

CPT 99387 codes initial preventive visits for new patients 65 and older

Medicare does not cover routine preventive exams under this code

Documentation requires comprehensive history, examination, and counseling components

Code differs from 99397 based on new versus established patient status

Reimbursement varies significantly between commercial payers and Medicare

What is CPT Code 99387?

CPT code 99387 represents an initial comprehensive preventive medicine evaluation and management service for new patients aged 65 years and older. The code encompasses age-appropriate history, physical examination, counseling, anticipatory guidance, and risk factor reduction interventions ordered or provided during the visit.

According to the American Medical Association (AMA) CPT code set, this service focuses on prevention rather than treatment of existing conditions. The comprehensive nature distinguishes it from problem-oriented evaluation and management codes.

The code applies when a provider sees a patient for the first time or when the patient has not received professional services from that provider or another provider of the same specialty within the same group practice during the past three years. This new patient definition comes directly from CPT guidelines maintained by the AMA.

CPT Code 99387: Documentation Requirements

Documentation for CPT 99387 must demonstrate three core components performed and recorded during the visit. Each component carries specific requirements that determine whether the code can be billed appropriately.

Comprehensive History for CPT 99387

The history component requires documentation of past medical, family, and social history relevant to the patient’s age and gender. For patients 65 and older, this typically includes cardiovascular risk factors, cancer screening history, functional status assessment, and social support systems. AI-powered clinical documentation tools help practices capture these elements consistently during the patient encounter.

Providers must document medication lists, allergies, and immunisation history. The review of systems should cover all major organ systems with attention to age-specific conditions such as cognitive changes, falls risk, hearing or vision impairment, and continence issues.

Comprehensive Examination Elements

The physical examination must be comprehensive, covering all body areas and organ systems appropriate to the patient’s age and gender. For older adults, this includes vital signs, cardiovascular assessment, respiratory examination, abdominal exam, musculoskeletal evaluation, and neurological screening.

Mental status evaluation becomes particularly important for patients 65 and older. Documentation should reflect cognitive assessment, mood screening, and functional capacity evaluation. Many practices use digital intake forms to gather baseline functional assessments before the examination.

Counseling and Anticipatory Guidance Requirements

Counseling must address age-appropriate preventive health topics. For patients 65 and older, this typically includes fall prevention, medication safety, advanced care planning, screening recommendations, and lifestyle modifications.

The documentation should specify topics discussed, recommendations provided, and educational materials given to the patient. Time spent on counseling does not determine code selection for preventive medicine services, unlike problem-oriented evaluation and management codes.

CPT 99387 Medicare Coverage and Limitations

Medicare does not typically cover routine preventive physical examinations under CPT code 99387. According to CMS guidelines, Medicare beneficiaries receive coverage for specific preventive services through the Initial Preventive Physical Examination (IPPE) or Annual Wellness Visit (AWV) codes instead.

The IPPE, coded as G402, covers new Medicare beneficiaries within the first 12 months of Part B enrollment. The AWV, coded as G0438 (initial) or G0439 (subsequent), provides preventive care for beneficiaries after the first year. These Medicare-specific codes differ substantially from CPT 99387 in scope and documentation requirements.

When billing CPT 99387 to Medicare patients, practices must provide an Advance Beneficiary Notice (ABN) informing patients of potential out-of-pocket costs. The ABN explains that Medicare does not cover the service and the patient agrees to pay for the visit themselves.

Commercial insurance plans typically cover CPT 99387 as part of preventive care benefits under the Affordable Care Act. Coverage frequency varies by payer, with most allowing one preventive visit annually. Practices should verify coverage before the appointment to avoid billing surprises for patients.

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Billing CPT 99387: Reimbursement and Fee Schedules

Reimbursement for CPT code 99387 varies significantly across payers and geographic regions. Commercial insurance companies typically reimburse the code at higher rates than Medicare Advantage plans. Practices should consult payer-specific fee schedules to understand expected reimbursement amounts.

The CMS Physician Fee Schedule provides baseline relative value units (RVUs) for the code, though Medicare rarely covers the service for routine preventive care. For 2026, the work RVU typically falls between 2.0 and 2.5, with geographic practice cost indices adjusting final reimbursement amounts.

Commercial payers often reimburse CPT 99387 between $150 and $250 per visit, depending on contract negotiations and regional market rates. Some plans cover the service at 100% with no patient cost-sharing when billed as preventive care.

Practices can access reimbursement data through claims management software that tracks historical payment patterns by payer and code. This data helps practices identify underpayments, optimise contracting negotiations, and forecast revenue from preventive services.

CPT 99387 vs 99397: Understanding the Difference

The primary distinction between CPT codes 99387 and 99397 lies in patient status. Code 99387 applies to new patients aged 65 and older, while 99397 covers established patients in the same age group receiving preventive care services.

Both codes require the same comprehensive documentation components: age-appropriate history, comprehensive examination, and counseling or anticipatory guidance. The clinical work performed remains identical regardless of patient status.

Reimbursement differs between the two codes. CPT 99387 typically commands higher payment rates than 99397, reflecting the additional administrative work and information gathering required for new patient encounters. The differential ranges from $20 to $50 depending on the payer.

Practices must verify patient status before coding the visit. Electronic health record systems can flag patient status automatically based on previous encounter dates and provider relationships, reducing coding errors that trigger claim denials.

Common CPT 99387 Billing Mistakes and How to Avoid Them

Incorrect patient status determination represents the most frequent billing error with CPT 99387. Practices mistakenly code patients as new when they meet established patient criteria, triggering downcoding or denial. Verifying the three-year lookback period before the visit prevents this error.

Another common mistake involves bundling preventive services with problem-oriented evaluation and management codes on the same date of service. When a patient presents for a preventive visit and the provider addresses a new or existing problem, both services can be billed using modifier 25 on the problem-oriented E/M code. However, documentation must clearly distinguish the preventive service from the problem-focused assessment.

Incomplete documentation causes many claim denials for CPT 99387. All three required components (comprehensive history, comprehensive examination, counseling) must appear in the medical record. Missing any component opens the practice to downcoding or denial during payer audits.

Practices sometimes bill CPT 99387 for Medicare beneficiaries without obtaining an ABN, leaving the practice unable to collect payment from the patient when Medicare denies the claim. The ABN must be signed before the service to remain valid for cost recovery.

Failing to verify coverage before the appointment leads to patient dissatisfaction and collection challenges. Some patients assume Medicare covers comprehensive preventive exams when it does not. Online booking platforms can prompt patients to verify their coverage before scheduling preventive visits.

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Conclusion

CPT code 99387 provides the coding foundation for comprehensive preventive care visits for new patients aged 65 and older. Success with this code requires attention to patient status determination, complete documentation of all three required components, and clear communication about coverage limitations, particularly for Medicare beneficiaries.

Practices that implement structured workflows for preventive care billing see fewer denials and higher reimbursement rates. Using practice management software that automates eligibility checks, enforces documentation standards, and tracks payment patterns by payer helps practices optimise revenue from preventive services while maintaining compliance with coding guidelines.

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