How To Use CPT Code 99396

CPT 99396 is a procedural code used for periodic comprehensive preventive medicine reevaluation and management of established patients aged 40-64 years. This article will cover the code description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, similar codes, and examples of cases where CPT 99396 can be used.

1. What is CPT 99396?

CPT 99396 is a procedural code used by healthcare providers to report periodic comprehensive preventive medicine reevaluation and management services for established patients aged 40-64 years. T

his code is utilized to bill for services that include age and gender-appropriate history, examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.

The primary purpose of these services is to maintain the patient’s overall health and prevent potential health issues by addressing age and gender-related risk factors.

2. 99396 CPT Code Description

The official description of CPT 99396 is: “Periodic comprehensive preventive medicine reevaluation 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, established patient; 40-64 years.”

3. Procedure

The procedure of CPT 99396 involves the following steps:

1. Obtaining a comprehensive age and gender-appropriate history of the patient, including past medical history, family history, and social history.
2. Performing a comprehensive physical examination tailored to the patient’s age and gender.
3. Providing counseling and anticipatory guidance to address potential health risks and promote overall wellness.
4. Implementing risk factor reduction interventions to minimize the likelihood of developing health issues in the future.
5. Ordering necessary laboratory and diagnostic tests to screen for potential health problems and monitor existing conditions.

4. Qualifying circumstances

Patients eligible to receive CPT code 99396 services are those who:

• Are established patients, meaning they have previously received professional services from the healthcare provider or another provider of the same specialty within the same group practice.
• Are aged between 40 and 64 years.
• Do not have any immediate medical concerns or acute health issues that require urgent attention.
• Require periodic health checkups as a preventive measure to maintain overall health and well-being.

5. When to use CPT code 99396

It is appropriate to bill the 99396 CPT code when:

• The healthcare provider performs a comprehensive preventive medicine reevaluation and management service for an established patient aged 40-64 years.
• The service includes a comprehensive history, examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures tailored to the patient’s age and gender.
• The primary purpose of the visit is to maintain the patient’s overall health and prevent potential health issues by addressing age and gender-related risk factors, rather than addressing a specific medical concern or acute health issue.

6. Documentation requirements

To support a claim for CPT 99396, healthcare providers must document the following information:

• A comprehensive age and gender-appropriate history, including past medical history, family history, and social history.
• A comprehensive physical examination tailored to the patient’s age and gender, with detailed findings and observations.
• Counseling and anticipatory guidance provided to the patient, including topics discussed and recommendations made.
• Risk factor reduction interventions implemented, along with the rationale for their use and expected outcomes.
• Any laboratory and diagnostic tests ordered, with an explanation of their necessity and relevance to the patient’s preventive care plan.

7. Billing guidelines

The billing guidelines and rules that apply to CPT code 99396 include:

• Only billing for services provided to established patients aged 40-64 years.
• Ensuring that the service includes a comprehensive history, examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures tailored to the patient’s age and gender.
• Documenting all required information to support the claim, as outlined in the documentation requirements section.
• Not billing CPT 99396 in conjunction with other preventive medicine codes for the same patient on the same date of service.
• If a separate and distinct problem-oriented evaluation and management (E/M) service is provided during the same encounter, it may be billed in addition to CPT 99396 with the appropriate modifier to indicate that it is a separate service.

9. Similar codes to CPT 99396

Five similar codes to CPT 99396 and how they differentiate from CPT 99396 are:

1. CPT 99395: This code is used for preventive medicine services for established patients aged 18-39 years, whereas CPT 99396 is for patients aged 40-64 years.
2. CPT 99397: This code is used for preventive medicine services for established patients aged 65 years and older, whereas CPT 99396 is for patients aged 40-64 years.
3. CPT 99385: This code is used for preventive medicine services for new patients aged 18-39 years, whereas CPT 99396 is for established patients aged 40-64 years.
4. CPT 99386: This code is used for preventive medicine services for new patients aged 40-64 years, whereas CPT 99396 is for established patients in the same age range.
5. CPT 99387: This code is used for preventive medicine services for new patients aged 65 years and older, whereas CPT 99396 is for established patients aged 40-64 years.

10. Examples

Here are 10 examples of cases where 99396 CPT code can be used:

1. A 45-year-old established patient presents for a routine annual physical examination.
2. A 55-year-old established patient undergoes a comprehensive preventive medicine reevaluation, including a detailed history, physical examination, and counseling on maintaining a healthy lifestyle.
3. A 50-year-old established patient receives a preventive medicine service that includes a comprehensive history, examination, and ordering of laboratory tests to screen for potential health issues.
4. A 42-year-old established patient undergoes a preventive medicine reevaluation that includes a comprehensive history, examination, and risk factor reduction interventions.
5. A 60-year-old established patient presents for a preventive medicine service that includes a comprehensive history, examination, counseling, and anticipatory guidance on age and gender-related risk factors.
6. A 48-year-old established patient undergoes a comprehensive preventive medicine reevaluation, including a detailed history, physical examination, and ordering of diagnostic tests to monitor existing conditions.
7. A 52-year-old established patient receives a preventive medicine service that includes a comprehensive history, examination, and counseling on maintaining a healthy diet and exercise regimen.
8. A 58-year-old established patient undergoes a preventive medicine reevaluation that includes a comprehensive history, examination, and risk factor reduction interventions, such as smoking cessation counseling.
9. A 63-year-old established patient presents for a preventive medicine service that includes a comprehensive history, examination, counseling, and anticipatory guidance on age and gender-related risk factors, such as menopause management.
10. A 40-year-old established patient undergoes a comprehensive preventive medicine reevaluation, including a detailed history, physical examination, and ordering of laboratory tests to screen for potential health issues, such as diabetes and high cholesterol.