Billing for Annual Wellness Visit: 60-Year-Old with Private Insurance
For a 60-year-old patient with private insurance presenting for an annual wellness visit, bill using CPT code 99386 (established patient, age 40-64 years) or 99387 (established patient, age 65+ years) depending on whether they are new or established to your practice. 1
Primary CPT Code Selection
Use CPT code 99386 for this 60-year-old patient if they are an established patient in your practice, as this code 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 patients aged 40-64 years. 1
If the patient is new to your practice, use CPT code 99385 instead, which is designated for new patients in this age range. 1
Private Insurance Coverage
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. 2, 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 coverage mandate stems from the Affordable Care Act, which requires private insurers to cover preventive services without cost-sharing. 2
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 (99213-99215 for established patients). 1, 2
When billing for both a preventive visit and a problem-oriented visit on the same day, ensure documentation clearly distinguishes between the preventive service and the separate problem being addressed. 1
This represents an important opportunity for addressing problems in a timely manner and reducing the risk of loss to follow-up. 2
Additional Billable Services
Bill appropriate 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
These additional services are typically covered separately from the wellness visit itself. 1
Documentation Requirements
Document all required elements to support the preventive medicine code, including 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
Proper documentation is essential to support the level of service billed and to avoid claim denials. 1
Critical Billing Pitfalls to Avoid
Do not use standard office visit codes (99213-99215) for routine wellness visits, as these are intended for problem-oriented visits and may result in 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
Do not substitute brief physical examinations for the comprehensive preventive services required for wellness visits. 3
Reimbursement Considerations
While private payers historically follow Medicare's lead in coverage decisions, reimbursement rates may differ by insurance carrier. 1
Ensure proper use of Place of Service codes and any required modifiers for specific payers, as billing requirements vary by insurance carrier. 1
Clinicians must be fairly reimbursed for encounter-based preventive care to meet ambitious health promotion and disease prevention goals. 2