What is the recommended billing level for a 53-year-old female's annual wellness visit covered by private insurance, using Current Procedural Terminology (CPT) codes?

Billing Code for Annual Wellness Visit

For a 53-year-old female's annual wellness visit covered by private insurance, use CPT code 99386 if she is new to your practice, or CPT code 99396 if she is an established patient. 1

Age-Appropriate Code Selection

• The correct code is determined by the patient's age on the date of service—at 53 years old, this patient falls into the 40-64 year age bracket for preventive medicine coding. 1
• CPT code 99386 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 40-64 years. 1
• For established patients in this same age range, use CPT code 99396 instead. 1

Private Insurance Coverage

• Private insurance plans must cover preventive wellness visits at 100% with no patient cost-sharing when billed with the appropriate preventive medicine codes, per USPSTF recommendations. 1
• This zero-cost coverage applies to preventive services with USPSTF "A" or "B" recommendations, which includes annual wellness visits for adults. 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. 1
• Documentation must clearly distinguish between the preventive service and the separate problem being addressed to support billing both codes on the same day. 1

Additional Billable Services

• Vaccine administration codes (90460-90461) and vaccine product codes should be billed separately if immunizations are administered during the wellness visit. 1
• Age-appropriate cancer screenings (such as mammography or colorectal cancer screening) discussed or ordered during the visit should be billed with their specific CPT codes. 1

Critical Documentation Requirements

• Document all required elements to support the preventive medicine code: 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

Common Pitfalls to Avoid

• Do not use standard office visit codes (99201-99215) for routine wellness visits—these are intended for problem-oriented visits and will result in inappropriate patient cost-sharing that should not apply to preventive care. 1
• Avoid upcoding by selecting a higher level code than supported by your documentation. 1
• Ensure proper use of Place of Service codes and any required modifiers for the specific insurance carrier, as billing requirements vary by payer. 1