Billing for Annual Physical Exam in 25-Year-Old Male with Private Insurance
For a 25-year-old male presenting for an annual physical exam with private insurance, bill CPT code 99385 (preventive medicine service, new patient, age 18-39 years) if this is his first visit to your practice, or CPT code 99395 (preventive medicine service, established patient, age 18-39 years) if he has been seen before. 1
Primary Coding Structure
Use CPT 99385 for new patients or 99395 for established patients - these codes specifically cover comprehensive age and gender-appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and ordering of appropriate immunizations and laboratory/diagnostic procedures for patients aged 18-39 years 1
Private insurance plans must cover preventive wellness visits at 100% with no copayment or coinsurance when billed with these appropriate preventive medicine codes 1
Critical Considerations for Young Adult Patients
Young adults in this age group require comprehensive preventive services including behavioral health screening, risk assessment, and counseling that extends beyond a basic physical examination 1
Documentation should address physical health, social and academic/occupational competence, emotional well-being, risk reduction behaviors, and injury prevention - all elements that justify the preventive medicine code level 1
Billing Additional Services on the Same Day
If you identify and address a significant, separately identifiable problem beyond the preventive visit scope, bill an additional E/M service (99201-99205 for new patients, 99211-99215 for established patients) with modifier -25 appended to the problem-oriented code 1
The -25 modifier specifically allows for same-day treatment of issues that would otherwise require a separate visit, representing an important opportunity to address problems efficiently 2, 1
The problem-oriented visit must be documented separately and represent a significant, identifiable service beyond the preventive care 1
Additional Billable Components
Bill vaccine administration codes (90460-90461) and vaccine product codes separately if immunizations are administered during the wellness visit 1
Age-appropriate screening tests discussed or ordered should be billed with their specific CPT codes 1
Documentation Requirements
Your documentation must include all required elements: comprehensive age-appropriate history, comprehensive examination, counseling/anticipatory guidance, and risk factor reduction interventions to support the preventive medicine code 1
For young adults specifically, ensure documentation addresses the broader psychosocial elements beyond just physical examination findings 1
Common Billing Pitfalls to Avoid
Never use standard office visit codes (99201-99205 or 99211-99215) for routine wellness visits - these are intended for problem-oriented visits and will result in inappropriate patient cost-sharing when preventive codes should be used 1
Do not bill only from time descriptors for preventive visits - code selection is based on the comprehensive nature of the service, not time spent 3
Avoid inadequate documentation, which is a common reason for claim denials - ensure your note supports the comprehensive preventive service billed 1
Confidentiality Considerations
At 25 years old, the patient is a legal adult, but if he remains on parental insurance, explanations of benefits may compromise confidentiality for sensitive services 1
Discuss confidentiality protections and billing arrangements with the patient, particularly regarding reproductive health, mental health services, and substance abuse screening that may be addressed during the visit 1