Billing Level for a 22-Year-Old New Patient with Private Insurance Establishing Care
For a 22-year-old new patient with private insurance establishing care, bill CPT code 99385, which covers a comprehensive preventive medicine visit for new patients aged 18-39 years. 1
Primary Billing Code
CPT 99385 is the appropriate code for this encounter, as it 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 this age range. 1
Private insurance plans must cover preventive wellness visits at 100% with no copayment or coinsurance when billed with this preventive medicine code, per USPSTF recommendations. 2, 1
Critical Considerations for Young Adult Patients
Young adults require more comprehensive preventive services than standard adult visits, including behavioral health screening, risk assessment, and counseling that takes additional time—insurers should recognize and pay for these preventive medicine codes for health and behavior assessment. 1
At 22 years old, the patient is legally an adult, but if they remain on parental insurance, explanations of benefits sent to parents may compromise confidentiality for sensitive services like reproductive or mental health care. 1
Discuss confidentiality protections and billing arrangements with the patient at the outset, particularly regarding reproductive health care, mental health services, and substance abuse screening. 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 service using CPT codes 99201-99205 for new patients with modifier -25 appended to the problem-oriented code. 2, 1
The -25 modifier allows 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. 1
Documentation must clearly distinguish between the preventive service and the separate problem being addressed when billing both services on the same day. 2
Additional Billable Services
Bill vaccine administration codes (90460-90461) and vaccine product codes separately if immunizations are administered during the wellness visit. 2, 1
Age-appropriate screening tests discussed or ordered during the visit should be billed with their specific CPT codes. 2, 1
Documentation Requirements
Documentation should include all required elements to support CPT 99385: comprehensive age-appropriate history, comprehensive examination, counseling/anticipatory guidance, and risk factor reduction interventions. 2, 1
For young adults specifically, documentation should address physical health, social and academic/occupational competence, emotional well-being, risk reduction, and violence and injury prevention. 1
Include documentation of immunization status review and any screening tests performed or ordered during the visit. 2
Common Pitfalls to Avoid
Do not 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. 2, 1
Avoid upcoding by selecting a higher level code than supported by your documentation. 2
Be aware that payment rates for young adult care are often inadequate, with private insurance rates frequently failing to cover the time needed to properly serve this age group, but this should not affect your coding accuracy. 1