Billing for New Wellness Check in 40-Year-Old with Private Insurance
For a 40-year-old patient with private insurance presenting for a new wellness check, bill using CPT code 99385 (preventive medicine service, new patient, age 18-39 years) or 99386 (preventive medicine service, new patient, age 40-64 years) depending on whether the patient has turned 40 at the time of service.
CPT Code Selection
Use CPT code 99386 for patients aged 40-64 years who are new to your practice, which covers comprehensive age and gender-appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and ordering of appropriate immunizations and laboratory/diagnostic procedures 1
For patients who are 39 years old at the time of service, use CPT code 99385 instead, as age-based coding is determined by the patient's age on the date of service 1
Private Insurance Coverage Considerations
Under the Affordable Care Act, private health plans must provide coverage without copayment or coinsurance for preventive services that have a USPSTF "A" or "B" recommendation, which includes annual wellness visits for adults 2
Private insurance typically covers preventive wellness visits at 100% with no patient cost-sharing when billed with the appropriate preventive medicine codes 2
The patient should not be charged any copayment, coinsurance, or deductible for the preventive wellness visit itself when using these codes 1
Billing for Additional Services During the Same Visit
If you identify and address a significant, separately identifiable problem beyond the scope of the preventive visit, you may bill an additional evaluation and management (E/M) service using modifier -25 appended to the problem-oriented E/M code (99201-99205 for new patients) 1, 3
When billing for both a preventive visit and a problem-oriented visit on the same day, ensure documentation clearly distinguishes between the preventive service and the separate problem being addressed 1
Be aware that billing both services may result in the patient being responsible for copayments or cost-sharing for the problem-oriented portion of the visit, even though the preventive portion remains fully covered 2
Documentation Requirements
Document all required elements to support the preventive medicine code, including comprehensive age-appropriate history, comprehensive examination, counseling/anticipatory guidance, and risk factor reduction interventions 1
Include documentation of immunization status review and any screening tests performed or ordered during the visit 1
For any laboratory tests ordered (such as lipid panels, diabetes screening, or other age-appropriate preventive screenings), bill separately using the appropriate CPT codes 1
Common Billing Pitfalls to Avoid
Do not use standard office visit codes (99201-99205) for routine wellness visits, as these are intended for problem-oriented visits and may result in patient cost-sharing that should not apply to preventive care 3
Avoid upcoding by selecting a higher level code than supported by your documentation 1
Do not substitute a brief focused examination for the comprehensive preventive examination required by the preventive medicine codes 1
Ensure you bill as a "new patient" (99385 or 99386) only if the patient has not received any professional services from you or another physician of the same specialty in your group within the past 3 years; otherwise, use established patient codes (99395 or 99396) 1
Additional Billable Services
Bill appropriate vaccine administration codes (90460-90461) and vaccine product codes separately if immunizations are administered during the wellness visit 1
Age-appropriate cancer screenings discussed or ordered during the visit (such as mammography for women, colorectal cancer screening) should be billed with their specific CPT codes 2