Billing for Annual Wellness Visit: 39-Year-Old Male with Private Insurance
For a 39-year-old male with private insurance, bill using CPT code 99385 (new patient) or 99395 (established patient) for the preventive wellness visit, which private insurance must cover at 100% with no patient cost-sharing. 1
Primary CPT Code Selection
- Use CPT code 99385 for new patients or 99395 for established patients aged 18-39 years, as age-based coding is determined by the patient's age on the date of service. 1
- These codes cover comprehensive age and gender-appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and ordering of appropriate immunizations and laboratory/diagnostic procedures. 1
- Do not use standard office visit codes (99201-99215) 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. 1
Private Insurance Coverage Requirements
- Private health plans must provide coverage without copayment or coinsurance for preventive services that have a USPSTF "A" or "B" recommendation, which includes annual wellness visits for adults. 1
- Private insurance typically covers preventive wellness visits at 100% with no patient cost-sharing when billed with the appropriate preventive medicine codes. 1
- This zero-copay requirement was established under the Affordable Care Act and has been shown to increase preventive care utilization. 2, 3
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 E/M service using modifier -25 appended to the problem-oriented E/M code (99201-99205 for new patients, 99211-99215 for established patients). 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
- The modifier -25 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. 4
Additional Billable Services
- Bill vaccine administration codes (90460-90461) and vaccine product codes separately if immunizations are administered during the wellness visit. 1
- Age-appropriate cancer screenings discussed or ordered during the visit should be billed with their specific CPT codes. 1
- Laboratory tests ordered should be billed separately using the appropriate CPT codes. 1
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
- For young adults specifically, address physical health, behavioral health screening, risk assessment, and counseling as these take additional time and are frequently needed. 5
Common Billing Pitfalls to Avoid
- Avoid upcoding by selecting a higher level code than supported by your documentation. 1
- Do not substitute a brief sports physical for a comprehensive preventive examination, as the preventive medicine codes require comprehensive services. 1
- Ensure proper use of Place of Service codes and any required modifiers for specific payers, as billing requirements vary by insurance carrier. 1