What is the appropriate billing level for a new patient with private insurance?

Billing Level for New Patient with Private Insurance

For a new patient with private insurance, bill using CPT code 99385 (ages 18-39) or 99386 (ages 40-64) for preventive wellness visits, or CPT codes 99202-99205 for problem-oriented visits based on medical decision-making complexity or time spent. 1

Preventive Wellness Visit Billing

If this is a routine preventive/wellness visit:

• Use CPT code 99385 for patients aged 18-39 years at the time of service 1
• Use CPT code 99386 for patients aged 40-64 years at the time of service 1
• These codes cover comprehensive age-appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and ordering of appropriate immunizations and laboratory/diagnostic procedures 1
• Private insurance must cover these preventive visits at 100% with no patient cost-sharing when billed correctly 1

Critical Documentation Requirements

• Document all required elements: comprehensive age-appropriate history, comprehensive examination, counseling/anticipatory guidance, and risk factor reduction interventions 1
• Include immunization status review and any screening tests performed or ordered 1
• Age-based coding is determined by the patient's age on the date of service, not their birthday 1

Problem-Oriented Visit Billing

If this is a problem-focused visit (not preventive):

• Use new patient E/M codes 99202-99205 based on either medical decision-making complexity OR total time spent 2, 1
• The 2021 coding changes eliminated the requirement to document physical examination findings to support coding levels 2

Time-Based Billing Option

• Time-based billing may generate higher revenue for visits lasting 20 minutes or longer compared to MDM-based billing 3
• Document total face-to-face time with the patient in your visit documentation 2
• Time-based billing requires documenting the exact minutes spent with the patient 4

MDM-Based Billing Option

• MDM-based billing generates higher revenue for shorter visits (10-15 minutes) 3
• Code based on complexity of medical decision-making without needing to track time 3

Billing Both Preventive and Problem-Oriented Services

If you identify a significant, separately identifiable problem during a preventive visit:

• Bill the preventive code (99385 or 99386) AND an additional E/M code (99202-99205) with modifier -25 1
• Documentation must clearly distinguish between the preventive service and the separate problem being addressed 1
• This allows appropriate reimbursement for both services without patient cost-sharing for the preventive component 1

Common Billing Pitfalls to Avoid

• Never use standard office visit codes (99202-99205) for routine wellness visits - this results in inappropriate patient cost-sharing 1
• Avoid underbilling - 55% of resident encounters are underbilled by an average of $45.26 per encounter 5
• Avoid overbilling - selecting codes not supported by documentation can result in compliance issues 1
• Ensure proper Place of Service codes and any required telehealth modifiers (e.g., modifier 95) are included 2

Private Insurance Specific Considerations

• Private insurers typically follow Medicare's lead but may have different reimbursement rates and specific billing requirements 1
• Verify payer-specific requirements for modifiers and Place of Service codes 1
• Be aware that out-of-network billing has increased from 26.3% to 42.0% for inpatient admissions, with mean potential patient financial responsibility of $2,040 6
• Confirm your in-network status to avoid surprise billing issues for patients 6

Additional Billable Services

• Bill vaccine administration codes (90460-90461) and vaccine product codes separately if immunizations are administered 1
• Age-appropriate cancer screenings discussed or ordered should be billed with their specific CPT codes 1
• Telephone care and care coordination services may not be reimbursed by most private insurers despite available CPT codes 2