CPT 99387 Guide (2026) Complete Billing, Documentation & Reimbursement Rules

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Preventive Medicine Visits for New Patients Age 65 and Older

Why This Code Gets Practices Into Trouble And Costs Them Revenue

There is a scenario that billing managers in geriatrics practices encounter far more often than they should: a provider sees a 68-year-old patient for an initial preventive wellness visit, spends an hour conducting a comprehensive evaluation, and the claim comes back denied. The denial reason? The patient is on Medicare, and CPT 99387 is not a covered service under Original Medicare. The staff appeals, the appeal is denied, the physician is frustrated, and somewhere in that process the practice either eats the cost or ends up billing the patient inappropriately.

That single mistake billing CPT 99387 to Medicare is the most common and most costly error associated with this code. But it is far from the only one. Commercial payers who do cover CPT 99387 often deny claims due to incomplete documentation, incorrect patient status (new versus established), or missing age verification at the payer level. For geriatrics practices that serve a mixed payer population, understanding exactly how this code works and when to use it versus G0438 or 99397 is not a coding detail. It is a revenue protection issue.

This guide gives you everything you need to bill CPT 99387 correctly in 2026: what it covers, who it applies to, what Medicare actually expects instead, how commercial payers handle it, what the documentation must include, and how to prevent denials before they happen.

FINANCIAL REALITY CHECK

Commercial payers reimburse CPT 99387 between $150 and $250 per visit depending on contract terms and geography. That is a significant revenue opportunity but only if the claim is billed to the right payer, with the right patient status, and with documentation that holds up to review. Practices that do not have a systematic workflow for this code are leaving real money on the table or generating denials they cannot afford to chase.

What Is CPT 99387? A Plain-Language Definition

CPT 99387 is the AMA-designated billing code for an initial comprehensive preventive medicine evaluation and management service provided to a new patient who is 65 years of age or older. This is a wellness visit not a problem-oriented encounter. The patient is not coming in because something hurts or because a condition is getting worse. They are coming in for a comprehensive health assessment focused on prevention, screening, early detection, and health maintenance.

The service includes:

•         An age and gender-appropriate history comprehensive, covering medical history, family history, social history, and review of systems relevant to the patient's age group

•         A physical examination appropriate to the patient's age and sex

•         Counseling and anticipatory guidance health education, behavioral risk factor reduction, and preventive recommendations

•         Risk factor reduction interventions tailored to the patient's identified risk profile

•         Ordering of laboratory or diagnostic procedures appropriate for age and risk level

The word "initial" in the code description refers to patient status this is for a new patient. A new patient, under the standard three-year rule, is someone who has not received a professional service from this physician or any other physician of the same specialty in the same group practice within the past three years. Once that patient is established, the correct code becomes 99397.

Code Family at a Glance: How 99387 Fits In

CRITICAL RULE — Medicare and CPT 99387

Original Medicare does not cover CPT 99387. Full stop. CMS explicitly excludes routine preventive physicals (CPT codes 99381–99397) from Medicare coverage per the Medicare Claims Processing Manual. If you submit 99387 to a traditional Medicare payer, it will be denied — and there is no valid appeal path because it is a statutory exclusion, not a coverage dispute. For Medicare patients 65 and older, use G0438 (Initial Annual Wellness Visit) or G0439 (Subsequent AWV). Never submit 99387 to Original Medicare.

Medical Necessity, Coverage Rules & Payer Behavior in 2026

Commercial Insurance — The Primary Payer for CPT 99387

CPT 99387 is recognized and reimbursed by most major commercial payers including Aetna, Blue Cross Blue Shield, Cigna, and UnitedHealthcare — but coverage details vary significantly by plan, state, and contract. Here is what practices need to know:

Payer Category	Coverage Behavior	Billing Guidance
Original Medicare	Does NOT cover CPT 99387 — statutory exclusion	Use G0438 (initial) or G0439 (subsequent AWV). Never submit 99387 to Original Medicare.
Medicare Advantage (MA)	Coverage varies by plan. Some MA plans cover preventive visits including 99387; others default to the AWV structure.	Verify individual plan benefits before billing. Do not assume MA follows Original Medicare rules.
Commercial Insurance (ACA plans)	Most ACA-compliant commercial plans cover one preventive visit annually at 100% with no cost-sharing under ACA preventive care mandates.	Confirm ACA-mandated coverage with the patient's specific plan. Correct coding prevents cost-sharing disputes at the front desk.
Medicaid	State-dependent. Most state Medicaid programs cover preventive services; verify the state-specific CPT crosswalk.	Check your state's Medicaid fee schedule for preventive medicine codes before billing.
Self-Pay	Patient responsibility for full cost of the visit. Quote fees in advance and document informed consent for charges.	Ensure ABN (Advance Beneficiary Notice) or equivalent financial consent is signed for Medicare patients who request a physical exam.

PRO TIP — Medicare Advantage Verification

Medicare Advantage plans are not bound by Original Medicare's exclusion of routine physicals. Some MA plans actively encourage preventive visits and reimburse 99387 at competitive rates. The error billing teams make is assuming "Medicare = no coverage." Always verify the specific MA plan benefits through the payer portal before scheduling a preventive visit — a two-minute eligibility check can save a $200 claim denial.

Documentation Requirements: What Must Be in the Record

Documentation is where the vast majority of CPT 99387 denials originate. Payers are not denying because the service was not performed — they are denying because the documentation does not prove it. A comprehensive preventive medicine note has specific components, and every one of them must be present and legible in the medical record.

Required Documentation Checklist for CPT 99387

DOCUMENTATION CHECKLIST — All Elements Required for CPT 99387

COMPREHENSIVE HISTORY

✓         Chief reason for visit — documented as preventive/wellness, not problem-oriented

✓         Complete past medical history including all prior diagnoses, surgeries, hospitalizations

✓         Family history — first-degree relatives; identify hereditary disease risk factors relevant to age 65+

✓         Social history — living situation, tobacco/alcohol/substance use, activity level, diet patterns, support system

✓         Complete review of systems — comprehensive, with attention to age-specific systems (cardiovascular, neurological, musculoskeletal, GI, urological/gynecological)

PHYSICAL EXAMINATION

✓         Age and gender-appropriate comprehensive physical exam (not a focused exam)

✓         Vital signs — BP, pulse, respiratory rate, weight, BMI, temperature

✓         Head, eyes, ears, nose, throat (HEENT)

✓         Cardiovascular — heart rate, rhythm, murmurs, peripheral pulses

✓         Pulmonary — lung sounds, respiratory effort

✓         Abdominal exam — organomegaly, masses, bowel sounds

✓         Musculoskeletal — joint mobility, fall risk assessment, gait evaluation

✓         Neurological — cognitive screen, reflexes, cranial nerves as indicated

✓         Skin — integrity, lesions, wound healing assessment

✓         Gender-specific components (breast exam, prostate screening discussion, pelvic as indicated)

SCREENING & RISK ASSESSMENT

✓         Cognitive impairment screening (e.g., Mini-Cog, MoCA, or equivalent validated tool)

✓         Depression screening (PHQ-2 or PHQ-9 documented with score)

✓         Falls risk assessment — history of falls, home hazard discussion

✓         Vision and hearing screening or referral

✓         Osteoporosis risk assessment (especially women 65+)

✓         Cardiovascular risk assessment — cholesterol, blood pressure history, smoking status

✓         Diabetes screening — fasting glucose or HbA1c based on risk

✓         Colorectal cancer screening status — when last performed or plan to schedule

COUNSELING & PREVENTIVE GUIDANCE

✓         Health risk reduction counseling — diet, exercise, smoking cessation, alcohol reduction

✓         Immunization review and update — influenza, pneumococcal, zoster, COVID booster status

✓         Anticipatory guidance for age-appropriate health concerns

✓         Advance care planning discussion documented (highly recommended)

✓         Safety counseling — driving assessment, home fall prevention, medication safety

ORDERS & PLAN

✓         All ordered laboratory tests documented with clinical rationale

✓         All ordered imaging or diagnostic studies documented

✓         Referrals to specialists documented with reason

✓         Follow-up plan documented with timeframe

✓         Patient education materials provided — noted in record

WARNING — The Documentation Trap

Payers do not deny because the service was not done. They deny because the note does not prove it was done. A note that says "comprehensive physical performed — all systems reviewed" without actually documenting each system's findings is not defensible documentation. Every element above must be explicitly present in the medical record. Copy-forward notes from a prior visit are a denial and audit magnet — each preventive visit note must be individualized to that encounter.

Step-by-Step Billing Workflow for CPT 99387

Correct billing is not just about the code — it is about the entire workflow from patient scheduling through claim submission. Here is the sequence that prevents denials before they happen:

STEP 01  |  Payer Verification Before the Visit

Confirm the patient's insurance plan and whether it covers preventive medicine visits (CPT 99387). Verify patient status — new patient or established? If the patient has been seen in the past 3 years by any provider of the same specialty in your group, use 99397 instead. If the patient is on Original Medicare with no supplemental commercial coverage, do not schedule as 99387 — schedule as a Medicare Annual Wellness Visit (G0438/G0439) instead.

STEP 02  |  Confirm Age Eligibility at Registration

CPT 99387 applies to patients aged 65 and older at the date of service. Verify the date of birth in the EHR before the visit. A 64-year-old patient should be billed under CPT 99386, not 99387 — a single year's difference triggers an automatic age-mismatch denial that cannot be overturned.

STEP 03  |  Use a Preventive Visit-Specific Documentation Template

CPT 99387 has distinct documentation requirements from a problem-oriented E/M visit. Providers should use a template that prompts for every required component — comprehensive history, full physical exam, risk assessments, counseling, and preventive orders. A generic SOAP note template is not sufficient and often leads to incomplete documentation.

STEP 04  |  Separate Preventive and Problem-Oriented Services (If Both Occur)

If the provider also addresses a separate, significant medical problem during the same visit, you may bill both CPT 99387 and an appropriate E/M code (e.g., 99213 or 99214). However, the E/M code must be appended with Modifier 25 to indicate it was a significant and separately identifiable service from the preventive exam. The problem-oriented E/M requires its own diagnosis code — not one that overlaps with the preventive visit intent.

STEP 05  |  Submit with Correct Diagnosis Codes

Use preventive care ICD-10 codes as the primary diagnosis for CPT 99387. Common options include Z00.01 (encounter for general adult medical examination with abnormal findings), Z00.00 (without abnormal findings), or age-specific preventive care codes. Do not use a chronic disease code as the primary diagnosis on a preventive visit claim — it converts the claim's intent and triggers scrutiny.

STEP 06  |  Confirm Frequency Limits with the Payer

Most commercial payers cover CPT 99387 once per year (every 12 months). Verify the specific frequency policy for each payer — some plans have different intervals. Submitting a second 99387 within 12 months for the same patient will result in a frequency-limit denial that cannot be overturned without a documented clinical exception.

STEP 07  |  Review the Claim Before Submission

Pre-submission claim scrubbing should check: correct CPT code (99387 not 99397 for new patients), correct payer routing (never to Original Medicare), Modifier 25 on any additional E/M code, diagnosis code alignment, and patient demographic accuracy (DOB, name, MBI/insurance ID). A single-field error on a preventive claim is a denial waiting to happen.

Modifier Guide for CPT 99387

Common Denial Reasons — And How to Prevent Each One

2026 Reimbursement Insights for CPT 99387

Understanding what CPT 99387 is worth in your market and what factors affect how much you actually collect is essential for accurate revenue projections and contract negotiations.

Payer Type	Typical 2026 Rate	Cost-Sharing	Key Variables
Commercial (PPO/EPO)	$150–$250 per visit	Often $0 under ACA preventive mandate; plan-specific	Geographic region, network contract rates, plan tier
Medicare Advantage	Varies; some plans cover, some exclude	Varies by MA plan design	Must verify individual MA plan benefits — no blanket rule applies
Medicaid	State fee schedule rate (often $80–$140)	Generally $0 cost-sharing for preventive services	State-specific coverage and rate; verify prior to billing
Original Medicare	Not covered	Patient responsible for full cost if billed incorrectly	Never submit 99387 to Original Medicare — use G0438/G0439
Self-Pay	Negotiated or posted fee schedule	100% patient responsibility	Provide Good Faith Estimate (GFE) in advance per No Surprises Act requirements

2026 REIMBURSEMENT INSIGHT

The 2026 Medicare Physician Fee Schedule final rule (CMS-1832-F) reaffirmed that non-facility settings receive more favorable RVU assignments for office-based services. For preventive codes billed in a physician office setting, work RVUs for CPT 99387 typically range between 2.0 and 2.5, with geographic practice cost indices (GPCIs) adjusting the final allowed amount. Practices with strong commercial payer contracts in urban markets often collect at the higher end of the $150–$250 range.

Real-World Billing Challenges in Geriatrics Practices

Beyond the coding rules, the day-to-day reality of billing CPT 99387 in a busy geriatrics practice involves workflow gaps that most billing guides do not address. Here is where the revenue actually leaks:

Front Desk Errors That Start Denials Before the Visit

•         Scheduling a Medicare patient for a "physical" without checking whether they should have a Wellness Visit (G0438) instead — the provider performs a comprehensive preventive exam, the billing team submits 99387, and the claim is denied before the patient even leaves the parking lot

•         Failing to document the new patient status verification in the scheduling notes when a denial comes back for new/established status, the billing team has no documentation to support their appeal

•         Not collecting insurance verification specific to preventive visit coverage a patient's plan may cover E/M visits but have different rules for preventive codes

Provider Documentation Gaps

•         Completing a thorough preventive exam but writing a note that reads like a problem-oriented visit — payers look for preventive visit language and structure; a SOAP-style note focused on diagnoses can cause a preventive claim to be reclassified and denied

•         Addressing a chronic condition during the preventive visit without appending Modifier 25 to the separate E/M code — this bundles the two services and results in the lower-paying code being paid while the higher one is denied

•         Missing cognitive screening documentation — for patients 65 and older, payers increasingly expect documented cognitive screening results (not just "cognitive function intact") as a core preventive visit component

Coding Staff Knowledge Gaps

•         Confusing the Medicare Annual Wellness Visit (G0438) with the AMA preventive visit code (99387) — these are entirely different services for entirely different payers, and the distinction must be hardwired into every coder on your team

•         Not cross-checking patient age on the date of service before code selection — a patient who turns 65 during the month should have this verified before 99387 is used; billing one code for a patient who was technically 64 at the time of service creates a non-overturnable age-mismatch denial

•         Billing 99387 annually without tracking whether the 12-month frequency window has been met a second claim within 12 months is automatically denied and stays denied

How MedCloudMD Solves CPT 99387 Billing for Geriatrics Practices

The billing errors described above are not signs of a poorly run practice. They are signs of a billing process that was not designed specifically for the complexity of geriatrics patients and the payer mix that comes with serving a predominantly 65-and-older population. That is exactly the problem MedCloudMD was built to solve.

Frequently Asked Questions

Q1: Can I bill CPT 99387 and G0438 for the same patient?

No. These are mutually exclusive services for different payers. G0438 is the Medicare Annual Wellness Visit code for Original Medicare beneficiaries. CPT 99387 is a commercial insurance preventive code for new patients 65 and older. You would never bill both on the same claim or for the same encounter. If the patient has both Medicare and a commercial supplemental plan, use G0438 for Medicare and check whether the supplemental plan has any applicable balance billing rules.

Q2: What is the difference between CPT 99387 and CPT 99397?

The distinction is patient status. CPT 99387 is for new patients aged 65 and older — those who have not been seen by a provider of the same specialty in your group within the past three years. CPT 99397 is for established patients in the same age group who have received prior care from your practice within the last three years. Using 99387 when the patient is actually established is a billing error that triggers a denial for incorrect patient status.

Q3: Can a Medicare Advantage patient receive a CPT 99387 preventive visit?

Possibly — it depends on the specific Medicare Advantage plan. Unlike Original Medicare, MA plans set their own benefit structures and some do cover routine preventive exams that align with CPT 99387. Always verify coverage with the individual MA plan before billing. Do not assume Medicare Advantage follows Original Medicare's exclusion of preventive physicals. A quick payer portal eligibility check before the visit will tell you whether this service is covered and at what frequency.

Q4: What happens if I bill a chronic disease code as the primary diagnosis on a CPT 99387 claim?

You will typically receive a denial with a diagnosis-code inconsistency reason. Preventive medicine visits should be submitted with preventive care ICD-10 Z-codes as the primary diagnosis — Z00.00 (encounter for general adult medical examination without abnormal findings) or Z00.01 (with abnormal findings) are the most common. Using a chronic disease code like E11.9 (Type 2 Diabetes) as the primary diagnosis on a preventive claim signals to the payer that this was a problem-oriented visit, not a preventive one, and the claim may be repriced or denied accordingly.

Q5: How often can CPT 99387 be billed for the same patient?

CPT 99387 is a one-time code by definition — it is for new patients. Once a patient has received an initial preventive visit under 99387, they become an established patient and subsequent preventive visits should be billed under CPT 99397. From a frequency standpoint, most commercial payers cover one preventive visit per year (every 12 months). Submitting a second preventive visit claim within 12 months — whether 99387 or 99397 — will typically result in a frequency-limit denial.

Q6: Do I need to document advance care planning to bill CPT 99387?

Advance care planning is not a required element for CPT 99387, but it is a best practice for geriatrics visits and strongly recommended for patients 65 and older. If advance care planning is performed during the same visit, it can be billed separately using CPT 99497 (first 30 minutes) with its own documentation — the discussion must be face-to-face, voluntary, and documented with the topics covered and the patient's or surrogate's participation. Some commercial payers cover CPT 99497 on the same date as a preventive visit; verify the payer's policy before billing.

About MedCloudMD: MedCloudMD is a U.S.-based medical billing and revenue cycle management company with deep expertise in geriatrics billing services. Our AAPC-certified coding team, combined with systematic claim scrubbing and payer-specific billing workflows, helps geriatric practices reduce denials, maintain compliance, and capture the full revenue their clinical work deserves. This article is published for educational purposes and reflects 2026 CPT coding standards and payer guidance current as of the date of publication. Always verify current payer policies and CMS guidance for specific billing decisions.

Sources: AMA CPT Code Set 2026 | CMS Medicare Claims Processing Manual | CMS Annual Wellness Visit Coverage Guidelines | CMS CY 2026 Physician Fee Schedule Final Rule (CMS-1832-F) | AAPC Preventive Medicine Coding Guidelines | AAFP Preventive Visit Coding Resources