Wellness Exam Billing Codes
For routine wellness visits, use CPT codes 99381-99394 for preventive care services, which are the standard codes for comprehensive wellness examinations across all age groups. 1
Primary Wellness Visit Codes
CPT codes 99381-99394 are the designated preventive care visit codes that should be used for wellness examinations, including those covered under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. 1
These codes are structured by patient age and whether the patient is new or established to the practice. 1
Medicare-Specific Wellness Visits
Medicare Annual Wellness Visits (AWV) have specific billing requirements established by the Centers for Medicare and Medicaid Services (CMS), effective January 1,2011, which include mandatory cognitive impairment assessment. 2
The AWV requires review of patient Health Risk Assessment (HRA) information, patient observation, and structured cognitive assessment tools for both patients and informants. 2
Adding Developmental or Additional Screening
CPT code 96110 should be used when developmental screening is performed during a wellness visit, reported in addition to the preventive care E/M code with modifier 25 appended to the preventive care code. 1
Code 96110 does not include physician work—it covers non-physician staff administering and scoring the screening tool, while the physician's interpretation is bundled into the E/M code. 1
CPT code 96111 is used for extended developmental testing (typically up to 1 hour) provided by the medical provider, including evaluation interpretation and report, also reported in addition to E/M services. 1
Billing for Complex Wellness Visits
When wellness visits require significantly more time or complexity than typical, use higher-level outpatient codes (99214-99215 for established patients, 99204-99205 for new patients) instead of or in addition to preventive care codes. 1
99214 is appropriate for detailed evaluations that are moderately complex or take at least 25 minutes with more than half spent counseling. 1
99215 is used for comprehensive, highly complex evaluations or those taking 40 minutes with more than half spent counseling. 1
Prolonged Service Add-Ons
CPT codes 99354-99355 can be added when face-to-face outpatient visits require considerably more time than typical—99354 for the first 30-74 minutes of prolonged services, and 99355 for each additional 30 minutes. 1
CPT codes 99358-99359 are available for non-face-to-face prolonged services using the same time increments. 1
Common Billing Pitfalls
Never use standard office visit codes (99211-99215) for routine wellness care when dedicated preventive care codes exist, as these may be rejected by payers. 3
Always append modifier 25 to the preventive care code when billing separately identifiable E/M services on the same day as screening procedures like 96110. 1
Ensure documentation clearly supports the level of service billed—inadequate documentation is the most common reason for claim denials. 3