Billing Level for 18-Year-Old New Patient Establishing Care
For an 18-year-old private insurance patient new to establishing care, bill using CPT code 99385 (preventive medicine service, new patient, ages 18-39 years), which should be covered at 100% with no patient cost-sharing under the Affordable Care Act's preventive services mandate. 1
Primary Coding Recommendation
Use CPT 99385 for this new patient preventive visit, as this code specifically covers comprehensive age and gender-appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and ordering of appropriate immunizations and laboratory/diagnostic procedures for new patients aged 18-39 years. 1
Private insurance plans must cover preventive wellness visits at 100% with no copayment or coinsurance when billed with the appropriate preventive medicine codes, per USPSTF recommendations. 1
Critical Adolescent-Specific Considerations
Adolescents require more comprehensive preventive services than standard adult visits, including behavioral health screening, risk assessment, and counseling that takes additional time. 2
The AAP recommends that insurers recognize and pay for preventive medicine codes for health and behavior assessment and counseling, risk screening, and intervention, which are more frequently needed and appropriate for adolescents. 2
Avoid the common pitfall of substituting a brief sports physical for a comprehensive preventive examination, as this fails to address the full scope of adolescent health needs. 3
Billing for Additional Services on Same Day
If you identify and address a significant, separately identifiable problem beyond the scope of the preventive visit during this encounter, you may bill an additional E/M service (99201-99205 for new patients) with modifier -25 appended to the problem-oriented code. 1
When billing both services, ensure documentation clearly distinguishes between the preventive service and the separate problem being addressed. 1
The AAP specifically recommends that insurers recognize the -25 modifier CPT code to allow for same-day treatment of issues that would otherwise require another separate health care visit, representing an important window of opportunity for addressing problems in a timely manner. 2
Additional Billable Services
Bill vaccine administration codes (90460-90461) and vaccine product codes separately if immunizations are administered during the wellness visit. 3, 1
Age-appropriate screening tests discussed or ordered during the visit should be billed with their specific CPT codes. 1
Laboratory tests ordered should be billed separately using the appropriate CPT codes. 3
Documentation Requirements
Document all required elements to support CPT 99385, 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 adolescents specifically, ensure documentation addresses physical growth and development, social and academic competence, emotional well-being, risk reduction, and violence and injury prevention. 2
Common Pitfalls to Avoid
Never use standard office visit codes (99201-99205) for routine wellness visits, as these are intended for problem-oriented visits and may result in inappropriate patient cost-sharing that should not apply to preventive care. 1
Do not upcode by selecting a higher level code than supported by your documentation. 3, 1
Be aware that payment rates for adolescent care are often inadequate, with Medicaid and private insurance rates frequently failing to cover the time needed to serve adolescents properly. 2
Confidentiality Considerations for This Age Group
At 18 years old, this patient is legally an adult, but be aware that explanations of benefits sent to parents (if the patient is on their insurance) may compromise confidentiality for sensitive services like reproductive or mental health care. 2
Consider discussing confidentiality protections and billing arrangements with the patient, particularly regarding reproductive health care, mental health services, and substance abuse screening. 2