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Last Updated: August 21, 2026
Key takeaways
CPT code 99396 covers a periodic comprehensive preventive medicine visit for an established patient aged 40 to 64.
The visit must include a comprehensive history, a physical examination, age-appropriate counseling, and orders for immunizations or labs.
Traditional Medicare does not pay 99396, so use G0438 or G0439 for a Medicare Annual Wellness Visit.
Practice management software like Pabau pre-fills the claim from the patient record and checks required fields before submission.
CPT code 99396 is the annual physical code for an established patient aged 40 to 64. It covers a periodic comprehensive preventive medicine reevaluation, billed once a benefit year by most plans. One fact decides more 99396 claims than any other. Traditional Medicare does not pay it.
Most commercial plans do pay, and they usually pay in full, so the code is worth getting right. Claims fail for a short list of reasons. Chief among them are the wrong age band, a missing modifier 25, and a diagnosis that reads like disease rather than wellness.
The sections below cover the documentation a payer expects, the diagnosis pairings that hold up, and the checklist to run before the claim goes out.
99396 covers the annual physical, not the sick visit
CPT code 99396 is the American Medical Association’s code for a periodic comprehensive preventive medicine reevaluation of an established patient aged 40 to 64.
“Established” means the patient has received professional services from the same physician or group practice within the past three years.
Purpose is what separates it from an evaluation and management (E/M) code. An E/M visit answers a complaint.
A 99396 visit happens because a year has passed, and the reason for the appointment is the calendar rather than a symptom. The AMA maintains the descriptor in its CPT code set and revises it annually.
- Code type: Preventive medicine service
- Patient status: Established only, never a new patient
- Age band: 40 to 64 years on the date of service
- Frequency: Usually once per benefit year, set by the payer
- New-patient counterpart: 99386, same age band
Two conditions decide whether 99396 applies
Both conditions have to hold at the same time. The patient must be established with the practice, and the patient must be 40 to 64 on the date of service. Miss either one and the claim is coded wrong before it leaves the building.
Age is measured on the date of service, never on the next birthday. A patient who turns 65 the following week still bills 99396. A patient who turned 65 the week before does not, even if the appointment was booked months earlier.
The order you check these in matters, though, because the payer overrides both of them. Work down the three questions below and the code answers itself.
A 99396 visit needs all four components in the note
The AMA descriptor names four components, and a reviewer expects to find all four in the chart. A visit that stops at the physical examination does not support 99396.
- Comprehensive history: Age- and risk-appropriate history covering review of systems, social history, family history, and current medications
- Comprehensive examination: A multi-system physical examination suited to the patient’s age, sex, and risk factors
- Counseling and anticipatory guidance: Risk factor reduction, health education, and age-specific advice such as cardiovascular risk or cancer screening
- Orders for immunizations and diagnostics: Immunizations such as flu, Tdap, or shingles, plus labs and referrals like a lipid panel, mammography, or colonoscopy
The note has to show that each one happened. A chart that records the examination but says nothing about counseling gives a reviewer grounds to downcode or deny.
Counseling is the component that goes missing most often, because the conversation takes place and never reaches the record.
Who pays for a 99396 visit, and who does not
The payer decides almost all of it. Traditional Medicare pays nothing for 99396, and you can confirm any code’s payment status in the CMS Physician Fee Schedule lookup. Commercial and ACA-compliant plans sit at the other end of the scale.
The annual preventive visit is one of the services non-grandfathered plans must cover in network with no cost sharing, under the federal preventive-services rules.
Billed as preventive and delivered in network, the visit costs the patient nothing. Same-day problem care is treated differently, as the modifier 25 section explains.
Your own remittances are the best rate source you have. Contracted preventive rates move with the plan, the region, and the negotiation, so a national average tells you very little about your own. Pull twelve months of paid 99396 claims by payer and you will have your own figure.
Medicare pays for wellness visits, just not with 99396
Medicare covers an Annual Wellness Visit (AWV) and has its own codes for it. Submit 99396 for a Medicare beneficiary and the claim denies, because Medicare excludes routine physical examinations by statute. Use these instead:
- G0438: Initial Annual Wellness Visit, the first one after the Welcome to Medicare visit
- G0439: Subsequent Annual Wellness Visit, billed each year after the initial one
The two visits are not the same service. An AWV is built around a health risk assessment and a personalized prevention plan, and it does not call for a head-to-toe examination. A patient asking for the full physical is asking for a service Medicare does not cover.
That patient can still choose to pay out of pocket. The provider may perform and bill 99396 as a non-covered service, provided the patient knows in advance that Medicare will not pay. Have them sign an Advance Beneficiary Notice of Non-coverage, form CMS-R-131, before the visit.
Two documents get mixed up here, so it is worth separating them. The ABN is a signed CMS form the patient completes beforehand, and it records their agreement to pay. A superbill is an itemized statement of what was done, handed over afterward for the patient’s own claim or records.
Medicare does not require an ABN for a service it never covers, but a signed one still settles the argument about the bill. If Medicare makes up a large share of your panel, the broader Medicare billing rules shape far more than this one code.
Modifier 25 is what lets a problem visit ride along
Bill both services and append modifier 25 to the E/M code, never to 99396. That is the whole rule. The rest is documentation.
The situation itself is routine. A patient comes in for the annual physical and mentions a new rash, or asks about knee pain that has been getting worse. The preventive visit still happened, and so did a separate problem visit, so both can go out on the same date.
- Confirm the acute or chronic issue sits outside the content of the preventive exam.
- Document the problem visit in its own part of the note, separate from the preventive documentation.
- Append modifier 25 to the E/M code, giving you 99213-25 or 99214-25.
- Bill 99396 on its own line with no modifier.
- Give each line the diagnosis that fits it: a wellness code for 99396, a specific diagnosis for the E/M.
Then comes the awkward part at the front desk. The preventive half carries no cost sharing, but the problem half runs through the patient’s deductible and copay like any other office visit.
A patient who came in for a free physical gets a bill, calls to complain, and the practice often writes it off. Saying so at check-in costs one sentence and saves the write-off.
Leaving modifier 25 off is a primary denial trigger, and some payers audit these pairs after they pay. The note has to show two services, not one visit described twice.
Pro Tip
A note reading ‘came in for annual physical, also discussed knee pain’ does not establish a separately identifiable service. Document the problem visit as though it stood alone, with its own history, assessment, and plan. That is what a reviewer looks for when the pair gets audited.
The primary diagnosis has to say wellness, not disease
Lead the 99396 line with a Z code. Payers expect a wellness or preventive encounter code in the primary position. A chronic disease code sitting there is a common cause of a downcode or a denial.
Chronic conditions still belong on the claim. Hypertension, diabetes, and hyperlipidemia can sit in the secondary positions when they were reviewed during the visit. They simply cannot lead.
What the chart note has to show if a payer asks
Every item below belongs in the note. A reviewer reading “annual physical completed, no concerns” has no way to match the note to the code. That is how a paid claim turns into a refund request.
- Age and established status confirmed in the chart header or demographics
- Comprehensive history covering the reason for the preventive visit, review of systems, past medical history, family history, and social history
- Examination findings recorded by organ system and appropriate to age and sex
- Counseling topics named individually, such as cardiovascular risk, diet, or smoking cessation
- Immunizations listed by name, with the dose given or the refusal recorded
- Diagnostic orders such as lab requisitions and referrals, each with its clinical reason
- Date of service, provider signature, and credentials present on the note
Where 99396 claims go wrong most often
Seven errors account for most 99396 denials, and each one is visible before submission.
- Wrong age band: The patient falls outside 40 to 64 on the date of service.
- New patient billed as established: Nobody at the practice has seen them in three years, so 99386 applies.
- Missing modifier 25: A same-day E/M goes out unmodified and the payer bundles it into the preventive visit.
- Medicare submission: The claim denies on arrival, and the visit should have been G0438 or G0439.
- Thin documentation: The note skips a required component, usually counseling or the orders.
- Wrong primary diagnosis: A chronic disease code leads the 99396 line instead of Z00.00 or Z00.01.
- Frequency limit exceeded: A second preventive visit lands inside the plan’s window and denies as a duplicate.
Denials cluster by cause rather than by payer, so group last quarter’s rejections by reason code before you change any process. Good denial management starts with that report, because it tells you which of the seven above is costing you money.
Run this check before the claim goes out
Seven questions, answered at the desk, catch nearly all of it:
- Is the patient 40 to 64 on the date of service?
- Has this practice seen them within the past three years?
- Is the payer anything other than traditional Medicare?
- Does the note cover history, examination, counseling, and orders?
- Is the primary diagnosis Z00.00 or Z00.01?
- Does any same-day E/M carry modifier 25 and its own diagnosis?
- Has the plan already paid a preventive visit inside its window?
It helps to know what happens next. The claim leaves your system, hits the clearinghouse, and gets tested against that payer’s edits before the payer ever sees it.
A rejection at that stage comes back within a day and can be corrected and resubmitted. It is not a denial, so it needs no appeal, which is why front-end checks are worth more than back-end ones.
Where 99396 sits among the preventive codes
99396 is one of a family. The CPT siblings differ only by patient status and age band. The Medicare G codes sit alongside them as the alternative for a different payer.
99401 is worth a note of its own. It bills preventive counseling as a separate service in roughly 15-minute units, and 99402 through 99404 cover longer sessions. It can run on the same day as 99396 when the session is documented on its own. Payer policy on that pairing varies, so check before you count on the revenue.
Pro Tip
Run a 90-day audit of your 99396 claims. Filter for three things: claims without a Z00.0x primary diagnosis, same-day E/M pairs missing modifier 25, and any claim sent to a Medicare payer. Those three filters surface most of your denial root causes in a single report.
How Pabau keeps a preventive claim clean before it goes out
The denials above share a root cause. The note and the claim get built in two separate steps, often by two different people. Counseling gets discussed and never charted.
The code gets picked from the appointment type instead of the patient’s age. Modifier 25 gets missed because the problem visit was added halfway through the encounter.
Practice management software like Pabau closes that distance by holding both in one record. Pabau’s billing and claims tools pre-fill the claim form from the patient record.
The CPT code attached to the service lands on the charge line, and the ICD-10 slots come from the recorded problem list.
Built-in ICD-10 and CPT lookup libraries let a biller confirm a code without leaving the claim. Before it can be sent, Pabau checks that the fields the payer requires are filled in.
Claims then go out electronically through a clearinghouse, with Claim.MD handling the US side for thousands of payers.
That pipeline also carries real-time eligibility checks, claim status tracking, and remittance posting. So your billers spend their time on claims that need a decision, not on ones missing a membership number.
Send preventive claims that pay the first time
Pabau builds the claim from the patient record, checks that required fields are complete, and submits electronically through Claim.MD in the US. Your billers chase fewer rejections and rework fewer preventive visits.
Conclusion
The payer decides more about a 99396 claim than the examination does. Check that first, then patient status, then age, and the coding part becomes close to mechanical.
What is left is documentation, and documentation only stays complete when it is written during the visit rather than reconstructed on Friday afternoon.
So pick one habit to fix this month. Pull your paid and denied 99396 claims for the last quarter and group them by reason. One step is usually behind most of the rejections.
Book a demo to see how Pabau ties the preventive visit note to the claim. Those checks then happen before submission instead of after a denial.
Continue your research
Need to see how a claim reaches the payer? Medical claims clearinghouse overview walks through how claims move from your practice to payers, and where rejections get caught first.
Denials piling up across your preventive codes? Denial codes in medical billing decodes the CARC codes your remittance shows when a 99396 claim comes back unpaid.
Trying to work out why a claim was paid short? Electronic remittance advice explains how to read the 835 file that says what was paid, what was not, and why.
Frequently asked questions
Can a nurse practitioner or physician assistant bill CPT 99396?
Yes, within their state scope of practice. In most states an NP or PA reports the preventive visit under their own NPI. Some commercial contracts still require the claim to go out under a supervising physician. Check the payer’s credentialing rules before the visit, not after the denial.
Does a telehealth visit qualify for 99396?
Usually not. The descriptor calls for a comprehensive multi-system physical examination, which a video visit cannot deliver. Most payers leave preventive medicine codes off their telehealth lists for that reason. A virtual conversation about risk factors bills better as counseling or as a problem-focused visit.
How do payers count the once-a-year limit?
Two ways, and they are not interchangeable. Some plans reset on the benefit year, so a January visit and a December visit both pay. Others count 365 days from the last preventive visit, which turns an early rebooking into a denial. Check the member’s plan at scheduling.
Are screening labs billed separately from 99396?
Yes. The code covers ordering the labs, not performing them. A lipid panel, the blood draw, and any in-office screening go out on their own lines with their own diagnosis codes. Mammography and colonoscopy referrals are billed by whichever facility carries them out.
