CPT 99381–99397: Complete Guide to Preventive Medicine Visits, Billing, Coding & Reimbursement in 2026
A patient books an annual physical, mentions a new knee pain halfway through, and leaves. Which code goes on the claim? One preventive code, a problem-oriented E/M, or both? Preventive visits look routine, yet code selection, patient status, benefits, and modifiers trip up claims every day. This guide walks through how CPT 99381–99397 work and what to check before you bill.
Quick Answer CPT 99381–99387 report preventive medicine visits for new patients. CPT 99391–99397 report them for established patients. Within each family, the code is chosen by patient age. Documentation should support the services reported, and payer benefits decide whether and how the visit is paid. |
What Are CPT 99381–99397 Codes?
They report comprehensive preventive medicine evaluation and management: an age- and gender-appropriate history, examination, counseling and anticipatory guidance, risk factor reduction, and the ordering of lab or diagnostic procedures. The focus is keeping a patient healthy, not treating a complaint, which is why they sit apart from problem-oriented E/M codes.
CPT 99381–99397 Code Breakdown
CPT Code | Patient Status | Age Range | General Use |
99381 | New | Younger than 1 year | Initial preventive visit |
99382 | New | 1–4 years | Initial preventive visit |
99383 | New | 5–11 years | Initial preventive visit |
99384 | New | 12–17 years | Initial preventive visit |
99385 | New | 18–39 years | Initial preventive visit |
99386 | New | 40–64 years | Initial preventive visit |
99387 | New | 65 years and older | Initial preventive visit |
99391 | Established | Younger than 1 year | Periodic preventive visit |
99392 | Established | 1–4 years | Periodic preventive visit |
99393 | Established | 5–11 years | Periodic preventive visit |
99394 | Established | 12–17 years | Periodic preventive visit |
99395 | Established | 18–39 years | Periodic preventive visit |
99396 | Established | 40–64 years | Periodic preventive visit |
99397 | Established | 65 years and older | Periodic preventive visit |
Age ranges reflect current CPT descriptors as we understand them. Confirm against your current AMA CPT book.
New Patient vs. Established Patient Preventive Visits
Under CPT rules, a new patient hasn’t received professional services from the physician or another physician of the same specialty in the same group within the past three years. Anyone else is established. The patient’s status picks the code family (99381–99387 or 99391–99397), and the age on the date of service picks the code within it.
Quick CPT 99381–99397 Code Check
NEW PATIENT → Review 99381–99387 | ESTABLISHED PATIENT → Review 99391–99397 |
AGE → Match age on the date of service to the code range | DOCUMENTATION → Confirm the record supports the services billed |
Not sure whether your preventive visit billing workflow is creating avoidable revenue leakage? Talk with our billing specialists. |
How to Select the Correct Preventive Medicine Code
Step | Question |
1 | Is the patient new or established? |
2 | What is the patient’s age on the date of service? |
3 | Is the encounter primarily preventive? |
4 | Does documentation support the services reported? |
5 | Are additional services separately reportable under applicable rules? |
Preventive Medicine Documentation
Documentation should support the services reported. Payers differ, and not every element is mandatory for every encounter. Records typically reflect a comprehensive age-appropriate history and examination, risk assessment, counseling and anticipatory guidance, screening considerations, immunization review when applicable, follow-up recommendations, and the medical necessity for any additional work. Note that the “comprehensive” preventive exam is not the same thing as a comprehensive exam under the older E/M documentation guidelines.
Preventive Medicine vs. Problem-Oriented E/M
| Preventive Medicine | Problem-Oriented E/M |
Purpose | Prevention and health maintenance | Evaluating or managing a problem |
Code selection | Patient status and age | Medical decision making or time |
Typical diagnosis | Encounter for examination (Z00 family) | Symptom or condition |
Same-day use | Base service | May be separately reported if significant and separately identifiable |
Avoid This Mistake Modifier 25 is never an automatic add-on. When a significant, separately identifiable problem is addressed beyond the preventive work, a problem-oriented E/M may be reportable with the modifier if the documentation and payer rules support it. Minor issues folded into the preventive visit don’t qualify. |
Real-World Billing Scenario: Established Adult Preventive Visit
Consideration | How the Billing Team Thinks It Through |
1. Patient status | Seen by the group within the last three years? Then established. |
2. Age | Say the patient is 52 on the date of service: the 40–64 band, so 99396. |
3. Preventive nature | Was the visit scheduled and delivered as a preventive exam? |
4. Documentation | History, exam, counseling, and risk assessment are recorded. |
5. Additional services | A new knee problem was evaluated beyond routine work; is a separate E/M with modifier 25 supported? |
6. Payer requirements | Benefit, frequency limits, and modifier policy checked. |
7. Final review | Diagnosis codes, linkage, and claim scrub complete. |
Common Billing Mistakes
Billing Mistake Checklist ☐ Incorrect patient status ☐ Incorrect age-based code ☐ Incomplete documentation ☐ Confusing preventive and problem-oriented services ☐ Incorrect modifier use ☐ Not verifying preventive benefits ☐ Incorrect diagnosis coding ☐ Duplicate billing ☐ Missing supporting documentation ☐ Ignoring payer-specific policies |
Why Preventive Medicine Claims Get Denied
Common drivers include benefit limitations, frequency restrictions, eligibility problems, wrong CPT selection, modifier errors, documentation gaps, diagnosis inconsistencies, payer-specific preventive rules, and duplicate or overlapping claims. These aren’t the only causes, but they come up often.
Could Your Preventive Claims Be at Risk?
☐ Patient eligibility verified ☐ Correct preventive CPT selected ☐ New/established status confirmed ☐ Age-based code confirmed ☐ Documentation supports the billed service | ☐ Preventive benefits verified ☐ Additional E/M reviewed correctly ☐ Modifier requirements reviewed ☐ Diagnosis coding reviewed ☐ Claim scrub completed |
If several boxes are unclear, your practice may benefit from a preventive billing workflow review.
Preventive Medicine Reimbursement in 2026
There is no single payment figure. Reimbursement depends on the payer, location, contract, patient benefits, provider participation, code selection, documentation, additional services, and payer policy. Verify actual payment against the contract or fee schedule. Many commercial and Medicaid plans cover preventive visits under their own benefit rules.
Medicare Note Traditional Medicare generally doesn’t cover 99381–99397 as routine physicals. It covers the Welcome to Medicare visit (G0402) and the Annual Wellness Visit (G0438/G0439), which have their own requirements. Check current CMS guidance and your MAC. |
Factor | Why It Matters |
CPT code | Determines the service reported |
Patient status | Determines new vs. established code family |
Age | Determines the applicable preventive code |
Payer | Rules and payment policies vary |
Benefits | Preventive coverage and frequency may differ |
Documentation | Supports the services reported |
Modifiers | May affect claims when applicable |
Diagnosis coding | Must accurately support the encounter |
Contract | Determines contracted reimbursement |
How Practices Can Improve Preventive Visit Revenue
Strengthen the steps before and after the visit: verify eligibility and preventive benefits before the appointment, select the code carefully, review documentation, scrub claims, learn payer-specific rules, monitor denials, follow up on A/R, analyze payment variances, run coding audits, and train staff on patient status and modifier use.
Frequently Asked Questions
Q: What are CPT codes 99381–99397 used for?
They report comprehensive preventive medicine visits for infants, children, adolescents, and adults.
Q: What is the difference between 99381–99387 and 99391–99397?
The first range is for new patients; the second is for established patients.
Q: How do I choose the correct preventive code?
Confirm new or established status, then match the patient’s age on the date of service, then confirm the documentation.
Q: Can a problem-oriented E/M be billed with a preventive visit?
Sometimes. A significant, separately identifiable problem may support a separate E/M with modifier 25, subject to documentation and payer policy.
Q: Does Medicare cover preventive medicine CPT codes?
Traditional Medicare generally doesn’t cover these as routine physicals, but covers other preventive visits such as the Annual Wellness Visit. Verify current CMS guidance.
Q: Why are preventive medicine claims denied?
Typical reasons include benefit limits, frequency rules, wrong age or status codes, modifier issues, and documentation problems.
Q: How can practices improve preventive visit billing?
Verify benefits first, audit coding, scrub claims, and track denials by payer.
MedCloudMD combines technology with human billing expertise to help practices with claims, denials, coding, eligibility, A/R, and reimbursement challenges. We can’t guarantee claim approval or payment. See our medical billing and revenue cycle services.
Sources & References: AMA CPT Professional Edition (preventive medicine services); CMS Medicare preventive services resources and Physician Fee Schedule; applicable Medicaid and payer policies.
Disclaimer This article is for educational and informational purposes and does not replace professional coding, compliance, legal, or payer-specific advice. CPT® is a registered trademark of the AMA. CPT and payer policies change, and coding and reimbursement requirements vary by payer. Verify current CPT, CMS, Medicare, Medicaid, and payer requirements before submitting claims. Actual reimbursement depends on contracts, benefits, policies, and claim circumstances. |
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