Billing Level for a 44-Year-Old New Patient Establishing Care with Private Insurance
For a 44-year-old patient with private insurance establishing care, bill CPT code 99386, which covers comprehensive preventive medicine services for new patients aged 40-64 years. 1
Primary Billing Code Selection
Use CPT 99386 for this new patient preventive wellness 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 in the 40-64 age range. 1
Age-based coding is determined by the patient's age on the date of service, so verify the patient is 44 years old at the time of the visit. 1
Private Insurance Coverage Expectations
Private insurance must cover this preventive wellness visit at 100% with no copayment or coinsurance when billed with the appropriate preventive medicine code (99386), as mandated for USPSTF "A" or "B" recommended preventive services. 1
Private payers historically follow Medicare's lead in coverage decisions, though reimbursement rates may differ. 2
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, bill an additional evaluation and management service using CPT codes 99201-99205 (for new patients) with modifier -25 appended. 1, 3
Documentation must clearly distinguish between the preventive service and the separate problem being addressed to justify billing both codes on the same day. 1
The -25 modifier allows for same-day treatment of issues that would otherwise require another separate healthcare visit, representing an important window of opportunity for addressing problems in a timely manner. 3
Required Documentation Elements
- Document all required elements to support CPT 99386, including: 1
- Comprehensive age-appropriate history
- Comprehensive examination
- Counseling/anticipatory guidance
- Risk factor reduction interventions
- Immunization status review
- Any screening tests performed or ordered during the visit
Additional Billable Services
Bill vaccine administration codes (90460-90461) and vaccine product codes separately if immunizations are administered during the wellness visit. 1, 3
Age-appropriate cancer screenings discussed or ordered during the visit should be billed with their specific CPT codes. 1
Critical Pitfalls to Avoid
Never use standard office visit codes (99201-99205) for routine wellness visits, as these are intended for problem-oriented visits and will result in inappropriate patient cost-sharing that should not apply to preventive care. 1, 3
Do not upcode by selecting a higher level code than supported by your documentation, as this can lead to claim denials and potential audit issues. 1
Ensure proper use of Place of Service codes and any required modifiers for your specific payer, as billing requirements vary by insurance carrier. 2