99386 CPT code, cpt 99386, 99386, cpt code 99386

99386 CPT Code | Description, Guidelines, Reimbursement, Modifiers & Examples

The 99386 CPT code can use for “New Patient Preventive Medicine Services.” It is recognized by the American Medical Association (AMA) even though it is no longer the most frequently used code. 

CTP code 99386, used for adults between the ages of 40 and 64, is eligible for a well-patient visit.

Patients who do not have a primary complaint can benefit from evaluation and management services, also known as E/M services, which are part of preventive medicine.

A patient’s overall health is far more critical to evaluate during a visit than any illness or injury (or the signs or symptoms of a disease or injury).

The CTP code 99386 can use by a physician who thoroughly examines the patient. The billing-related topics, such as coding, compliance, and documentation, can be discussed in CPR’s “Coding Corner.” 

As the managing editor of AAPC, an organization that provides education and credentials to those working in the healthcare industry, John Verhovshek has this month’s hint to share with our readers.

Codes will assign by taking into account the patient’s age and whether they are new (99381-99387) or established (99381-99387) patients into consideration (99391-99397). Companies can be classified as either new or appointed based on the “three-year rule,” according to CPT guidelines. 

According to the patient’s belief, doctors working in a group practice might have treated the patient within the last three years and six months.

Evaluation and Management Services Guidelines in the CPT codebook include a decision tree that compares and contrasts new patients with those who have been in practice for a long time.

Preventive medicine services necessitate a thorough medical history, age-appropriate physical exams, and advice on healthy lifestyle choices. It is also possible to modify the test so that it takes age and gender into account.

For example, a boy in fourth grade and a woman in her twenties will have very different requirements for taking an exam.

Early childhood services assess a child’s development in various ways, including their ability to speak, crawl, and sleep and their physical growth, as measured by their height, weight, and head circumference.

Among the possible recommendations are experimenting with new foods, using car seats and other safety measures, and so on.

99386 CPT Code Description

The CPT manual describes CPT 99386 as: “Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years”

CPT code 99386 specifies an initial comprehensive evaluation and management for preventive medicine, including all of these components. In addition, it includes screening for adolescent scoliosis and growth and vaccination assessments.

The prostate, penis, scrotum, and testes can examine by males of any age. It is possible to do this during an elderly patient’s examinations.

During the consultation, the doctor can inquire about the patient’s occupation and other family-related topics. 

PSA testing can become more critical as patients get older. Patients are not required to pay a co-payment for preventive services under the Patient Protection and Affordable Care Act (PPACA).

Insurance policies and reporting requirements can differ from one company to the next. It can confirm by CPT Assistant. 

If a particular E/M service performs on the same day as chemotherapy or non-chemotherapy injections or infusions, a new patient’s CPT 99386 must include CPT modifier 25.

Children, adolescents, and adults are all included in the 99381-99397 E/M reporting codes.

As a patient’s age increases, so do the scope and intensity of services provided. The E/M department offers various preventive services to women over 28. One of these services is a pelvic exam. 

Billing Guidelines

Reporting for breast exams with CPT code 99386 is inappropriate because they can be part of a comprehensive preventive medicine E/M service. Third-party payers can require a different method of writing these services.

ICD-10 codes can attach to each service that can be the bill, indicating the root cause of the service provided for billing CPT 99386.

In the absence of a patient complaint, “Z codes” should be used (Factors influencing health status and contact with health services). Using this as an example, here’s an example:

  • An eight-day-old newborn must have a Z00.110 checkup to be considered a “newborn.”

A doctor should examine an 8 to 28-day-old baby for a complete physical examination. The results of a child’s routine checkup revealed something unexpected. The pediatrician did not notice any abnormalities during the child’s annual review.

  • If an adult medical examination reveals anything out of the ordinary, the proper diagnostic code is Z00.01.
  • Results from the gynecological test Z01.411 were erratic.
  • The gynecological exam Z01.419 turned up nothing abnormal.

Depending on the patient’s age and whether or not they are a new or returning patient, these codes can group into different categories.

When determining which billing code to use, the patient’s age is at the time of the bill generation. Preventive medicine codes include the following:

Evaluation and management (E&M) of a person entails a physical examination, the collection of an extensive and age- and generally-appropriate medical history, the implementation of counseling and guidance interventions and the reduction of risks, and the request for tests and laboratory work. 99381 a newcomer; 99382 an amateur (age younger than one year)

An adult new patient between the ages of 40 and 64 uses CTP code 99386, While chronically ill 99393 patients; children under 18 (age 5 through 11 years). The 99395 category includes patients between 18 and 39 who have been receiving treatment for at least six months.

Preventive medication can usually prescribe to new patients who meet the criteria for an age-based code selection after completing a thorough physical examination. One of these services is the examination, which includes gathering relevant patient history. 

Preventive inspections are not required to report minor or self-limiting issues or complaints if the necessary E/M components are available to the clinician when a problem-oriented E/M service is unavailable. 

CPT 99386 And Modifier 25

Use modifier 25 for CTP code 99386. Modifier 25 could be helpful in diagnostic or surgical procedures as a preventative measure.

Modifier 25 can be used for the 99386 CPT code to indicate preventive services when test results can use in diagnostic or therapeutic benefits on the same day as a screening service. The Affordable Care Act was a direct cause of this change.

Preventative services evaluations can generate reports like assessments of other types of services that can create accounts. MDM is the most likely problem assessment code used in this situation.

It is possible to bill for two separate procedures during the same exam because of modifier 25. To ensure full reimbursement, you must understand the proper application of this modifier, including which codes it can and cannot use with other CTP codes.

More often than not, colonoscopies can use to detect polyps that are leaking fluid (code 45378). When it happens on the same day, this happens.

As the patient ages, comprehensive preventive services typically include well-patient exams for established patients who represent them in evaluating and managing their overall health conditions.

Patients receiving care for an extended period are more likely to benefit from these exams. Modifier 25 mandates that a substantial post-procedure evaluation and management service can provide.

Any time a doctor adds this modifier, the patient’s condition requires a significant, separately identifiable E/M service to be performed (identified by a CPT code).

Using 25 modifiers when billing for postoperative services related to a previous surgery is not recommended. In addition, there is no need to include modifier 25 if the purpose of the office visit is solely to provide emergency medical care (also referred to as E/M care).

Adding a modifier 25 to the bill is unnecessary if a minor procedure can perform on the same day as an E/M procedure.

If a patient’s chest hurts while exercising, they should see a cardiologist immediately. The patient has a strong family history of high cholesterol and blood pressure. Due to his professional judgment, the doctor orders a cardiovascular stress test for the same day as your appointment. It is a simple example of CTP code 99386. 


The government will pay for one annual checkup for Medicaid-eligible adults. Before an adult can undergo a physical examination, the following conditions can meet: “People over 40 can examine at least once every two years.”


The CPT Assistant will refer to a colonoscopy with polypectomy when screening for colon cancer (for example, 45383 Colonoscopy, Flexible, Proximal to Splenic Flexure; with ablation of tumor). The modifier 25 can use when referring to commercial carriers. However, in the eyes of Medicare, modifier 25 is not an acceptable modifier.

A polyp can remove during a Medicare screening colonoscopy by entering the appropriate removal code, such as CPT 45383. These procedures can use to remove polyps, tumors, or other lesions that are difficult to remove using hot biopsy forceps, bipolar cautery, or other techniques. Likewise, remove lesions that cannot be removed using hot biopsy forceps, bipolar cautery, or snares.

A patient seeks treatment from a cardiologist after experiencing chest pains while exercising. The patient’s medical history includes hypertension and high cholesterol. A visit to the doctor’s office determines that the patient requires a cardiovascular stress test performed on the same day.

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