Preventive visit codes (CPT 99381-99397) are age-based and used for comprehensive health maintenance, screening, and counseling. Codes vary by patient age: 99381 (under 1), 99382 (1-4), 99383 (5-11), 99384 (12-17), 99385 (18-39), 99386 (40-64), 99387 (65+). Medicare uses G0438 (initial Annual Wellness Visit) and G0439 (subsequent). Preventive visits are covered at 100% with no deductible under ACA-compliant plans and Medicare. If an acute problem is identified during a preventive visit, bill the preventive code alone—do not separately bill an E/M unless the problem is substantial and requires distinct documentation (use modifier 25). Focus preventive visits on screening, health history, risk assessment, counseling, and recommendations.
Select the preventive code based on age at the time of service. Code 99381-99387 are used for established patients receiving comprehensive preventive visits (annual physical). Medicare beneficiaries bill G0438 (initial wellness visit, ages 65+) or G0439 (subsequent wellness visit). Do not bundle preventive codes with E/M codes (99211-99215) on the same day unless both are distinct and separately documented. If an acute problem arises during the preventive visit, address it briefly but do not bill a separate E/M unless it requires substantial additional time, complexity, and distinct documentation with modifier 25. Most practices include minor acute problems in the preventive visit without additional coding.
Preventive visits do not require prior authorization. They are covered automatically by all payers at 100% of allowed amounts (no deductible, copay, or coinsurance) under ACA compliance rules. Annual wellness visits are typically covered once per calendar year. Some plans allow preventive visits more frequently if the provider documents medical necessity (new patient, health changes). Verify frequency limits with the patient's plan. Preventive codes cannot be billed twice in the same calendar year to the same payer without documentation of significant health status change.
Preventive visit codes are not bundled with E/M problem-focused codes when modifier 25 is applied to the E/M. However, if a patient presents for preventive care and a minor acute problem is identified, address it within the preventive visit without billing additional codes. Use modifier 25 on the E/M code (e.g., 99214-25) only if the acute problem is complex enough to require a substantial, separate assessment and plan beyond the preventive visit scope. Do not apply modifier 25 to the preventive code. If only the preventive visit occurs, do not use any modifiers.
Document age-appropriate health history review, physical examination findings (vital signs, general exam, cardiac, respiratory, abdominal, neurological, skin), and screening recommendations (cancer screening, cardiovascular risk assessment, vaccinations, mental health screening). Include a health risk assessment (USPSTF guidelines, preventive care recommendations). Document counseling provided (exercise, diet, smoking cessation, substance use, injury prevention). Note recommendations for imaging, labs, or referrals (e.g., colorectal screening, lipid panel, depression screening). If an acute problem is addressed, document it separately if modifier 25 is used; otherwise, briefly mention it as an incidental finding managed in context of preventive visit.
Not unless the hypertension workup is substantial. A brief check and referral to manage hypertension separately is part of preventive care. However, if you perform a detailed hypertension evaluation with labs, EKG, and complex medication management during the preventive visit, use modifier 25 on a separate 99213-99215 E/M code and document it distinctly.
Yes. Preventive visit is appropriate for established patients regardless of chronic disease status. The visit focuses on screening, health counseling, and preventive measures. If diabetes management and medication adjustments are the focus, bill E/M instead. If the patient is stable and the visit is comprehensive health maintenance, bill preventive.
Address the acute symptom first (unless trivial). Bill the appropriate E/M code based on complexity. If the acute problem is complex and time-consuming, do not bundle preventive. If the acute problem is minor and quickly addressed, bill preventive and include the acute issue. Document the decision clearly.
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