99385 CPT Code: Complete Guide to New Patient Preventive Visits

99385 CPT code is for a comprehensive preventive medicine evaluation and management for a new patient in the 18-39 age group. The code applies to a comprehensive preventive assessment that is completed by the provider, which includes an age/gender specific history and examination, counseling, anticipatory guidance, and risk factor reduction. To get the reporting right, the patient’s age, whether or not the patient was new, and documentation, as well as coverage by the payers, and any other services provided during the encounter must be considered.

Quick Answer

99385 Cpt code – E/M comprehensive preventive medicine evaluation, new patient, ages 18-39. The service is directed toward preventive assessment, age and gender appropriate history and examination, counseling, anticipatory guidance, risk reduction, and appropriate preventive testing or recommendations. The 99385 code is not used based on medical decisions or a time limit, unlike some problem-oriented codes used in the outpatient E/M.

99385 CPT Code at a Glance

Before the detailed billing and documentation requirements, first let’s look at the basic code characteristics. New patient, age, preventive, documentation and coverage by the payer are the most critical elements to confirm.

99385 CPT Code Description

The 99385 Cpt code is a preventive medicine evaluation and management code. It is designed for a new patient aged 18-39 at the first comprehensive preventive check-up. It is not primarily about a specific illness or complaint but is about the health of the person and what can be done to prevent the illness, or what screening is indicated and the need to prevent the illness.

Multiple components of a comprehensive preventive encounter may occur in the same visit. Depending on the patient’s situation, the provider can examine medical and family history, conduct a suitable physical exam, discuss lifestyle and health risks, give forward-looking advice, and order laboratory or diagnostic tests as appropriate.

Common components include:

• Age and gender appropriate history
• Comprehensive preventive examination
• Preventive counseling
• Anticipatory guidance
• Risk factor reduction
• Appropriate screening recommendations
• Appropriate laboratory orders
• Appropriate diagnostic procedure orders
• Preventive health planning

The medical record should support the services actually performed during the encounter. A generic physical examination statement alone may not adequately demonstrate the scope of a comprehensive preventive service.

Who Qualifies for 99385 Cpt code?

The first step in selecting 99385 Cpt code is confirming that the patient meets the basic eligibility criteria. The patient should be a new patient and should be between 18 and 39 years old on the date of service. The encounter must also qualify as an initial comprehensive preventive medicine service under the applicable coding and payer rules.

New patient status should be reviewed carefully because it is not always based on whether the patient has recently visited the same physical office. Applicable E/M coding rules consider previous professional services provided by the physician or another physician of the same specialty within the same group, so historical records may need to be reviewed when status is uncertain.

Age Requirement

The patient must be 18 through 39 years old for 99385. If the patient is younger or older, another preventive medicine code may apply based on the patient’s age and new or established status. For instance, a 42-year-old new patient would be classified in the age group 99386 and not 99385. A 31-year-old established patient for a periodic preventive examination would be the appropriate code.

Preventive Medicine CPT Code Family

The preventive medicine code family is organized around the patient’s age and whether the patient is new or established. This makes patient status and age two of the first elements coders should verify before selecting a preventive medicine code.

This structure makes 99385 versus CPT Code 99395 an especially important distinction for adult preventive visits. Either code can be used with patients ages 18-39; 99385 for initial visit with a patient that is new to care; 99395 for periodic preventive service with a patient that is established.

What Does 99385 Cpt code Include?

A thorough preventive examination can include multiple aspects of the patient’s entire health. The documentation should show the services the provider performed to accomplish the reported preventive encounter, but the documentation will vary depending upon the patient’s age, health risks, history, and preventive needs.

Medical and Family History

Medical and surgical history, medication, allergy, family and social history may be reviewed by the provider. Other risk information may also be included where relevant to preventive care, in addition to lifestyle factors. The documentation should reflect information that was actually obtained or reviewed. Copying an old history into a new encounter without updating it can create documentation concerns.

Physical Examination

The provider conducts examinations relevant to preventive needs, age, and gender. The medical record should not solely consist of a general examination finding like “physical exam normal. The extent of the examination should be consistent with the provider’s documentation and the preventive service performed. When the record does not indicate a comprehensive examination, this should not be taken as a given by coding staff.

Preventive Counseling

Preventive counseling can involve prevention of disease, lifestyle choices, and health risks. Nutrition, physical activity, tobacco use, alcohol use, substance use, sexual health, weight management, injury prevention and other risk factors may be discussed, depending on the circumstances.

Counselling needs to be pertinent to the patient’s preventive needs and needs to be recorded in the medical record. A brief discussion of a minor issue should not automatically be interpreted as a separately billable problem-oriented E/M service.

Screening and Diagnostic Orders

A preventive visit may lead to appropriate screening laboratory or diagnostic orders. These services may be separately reportable when they have their own CPT or HCPCS codes and meet applicable coverage and medical necessity requirements. The 99385 code does not replace individual laboratory, imaging, immunization, or other procedure codes. Each separately reportable service should be reviewed according to its own coding and payer requirements.

Is 99385 Cpt code Based on Time?

No. 99385 Cpt code is not selected based on a time limit. Preventive medicine codes are not organized the same way as office and outpatient E/M codes that are available based on medical decision making or total time. It does not require a specific amount of time with the patient to make 99385. However, the emphasis with coding should be on the eligibility for the code and the documentation supporting the comprehensive preventive service.

Is Medical Decision-Making Required for 99385?

The code selection method for the primary code 99385 is not medical decision making. The MDM level should not be used to identify the need for a preventive medicine code, rather the MDM level should be assigned by the coder.

The primary considerations are patient age, patient status, preventive purpose, and the services documented during the encounter. If the provider separately evaluates a medical problem, that portion of the encounter should be reviewed independently to determine whether another E/M code may be supported.

99385 CPT Code vs 99395

Both medical cpt codes 99385 and 99395 treat patients in the age range of 18-39, and these codes are often confused. The primary difference between them is that 99385 is for new patients, while 99395 is for established patients who are having periodic preventive care.

For example, a 24-year-old patient who qualifies as new and receives an initial comprehensive preventive evaluation may be reported with 99385. If that same patient returns later as an established patient for a periodic preventive examination, 99395 would generally be considered when the encounter meets its requirements.

99385 CPT Code RVU: 2026 Values

The 99385 CPT code has a 2026 work RVU of 1.92. RVUs are the relative resources used to deliver a service and are split into work, practice expense and malpractice. CMS uses these components with geographic adjustments and a conversion factor when calculating Medicare Physician Fee Schedule payment.

99385 RVU Breakdown for 2026

These values show why the total RVU differs between office and facility settings. The work and malpractice components remain the same, while the practice expense component changes based on where the service is furnished.

99385 CPT Code vs 99204

The other significant comparison is between 99385 and 99204. Both codes can be used when a new patient is seen, but for a different kind of encounter and shouldn’t be used in place of each other.

A new patient who comes primarily for a comprehensive preventive examination may qualify for 99385. A new patient who presents primarily for evaluation and management of a medical problem should generally be evaluated under the applicable office or outpatient E/M codes instead.

It is important to note that not every preventive encounter is a problem oriented E/M service because of multiple medical problems. A paper-based time log does not constitute evidence of 99385 even if the encounter is labeled as a physical, if it’s actually for a medical complaint.

Can 99385 Be Billed With Another E/M Code?

An E/M service performed for a problem could also be reported on the same date as a preventive medicine service, at times. The E/M service must be substantial, distinct and necessary beyond the routine preventive encounter.

If the requirements are met, modifier 25 will be used to append to the additional E/M code. The documentation should clearly show that the separate evaluation and management work is done and not just indicate that another medical problem was mentioned.

Example

A patient comes to the office for a complete preventive checkup and examination for the first time at age 29. The patient experiences aggravating migraine symptoms during the encounter and the physician conducts a separate evaluation that involves history, assessment, treatment planning, medical decision making.

If the other work fulfills the applicable requirements, both the preventive service and the problem oriented E/M service can be reportable. Modifier 25 can be used on the additional E/M code when the documentation meets the criteria for the separate service and the payer’s requirements are met.

99385 CPT Code Modifiers

Modifier use should be based on the circumstances of the encounter and the payer’s requirements. Modifiers should not be added simply because they may increase payment or bypass an automated claim edit.

Modifier 25

Modifier 25 is particularly relevant when a separately identifiable problem-oriented E/M service is performed during the same encounter as a preventive service. The additional service must be significant and medically necessary, with documentation showing work beyond the preventive examination.

Modifier 33

Modifier 33 may be relevant to preventive services under applicable payer policies. Its use depends on the service, payer, and coverage requirements, so it should not be automatically appended to every 99385 claim.

Modifier 59

Modifier 59 is typically used to identify separate procedures. It should not be routinely attached to 99385 just to satisfy a payer edit, and coders should make sure to confirm if the situation warrants the use of this code.

99385 CPT Code Documentation Requirements

Strong documentation should demonstrate why the preventive medicine code was selected and what services were performed. The record should support the patient’s age, new patient status, preventive purpose, examination, counseling, and other relevant preventive activities.

Important documentation elements may include:

• Patient age
• New patient status
• Relevant medical history
• Family history
• Social and lifestyle history
• Physical examination findings
• Preventive counseling
• Risk assessment
• Anticipatory guidance
• Screening recommendations
• Laboratory or diagnostic orders
• Abnormal findings
• Follow-up recommendations
• Separately evaluated medical conditions

Description of the encounter based on documentation, not on copying and pasting. Templates can help to create uniformity, but they should be kept up to date to accurately reflect the patient’s situation and services offered.

Common Documentation Problems

Several documentation problems can make a 99385 claim difficult to support. One common issue is an examination documented only as “normal” without enough information to demonstrate what was evaluated. Another concern occurs when the note focuses almost entirely on a specific medical complaint while the claim reports a comprehensive preventive service.

New patient status can also become an issue when prior professional services are not reviewed. Practices should verify the patient’s history when necessary rather than relying solely on registration information. Preventive counseling should also be documented when it forms part of the encounter. The record should identify relevant topics addressed instead of using vague language that does not explain the preventive work performed.

99385 CPT Code Billing Guidelines

Coding staff should verify patient eligibility, service type, documentation and payer requirements prior to submitting 99385 CPT Code claims. Many errors can be detected by a consistent review process before the claim is sent to the payer.

Confirm Patient Age

On the date of service the patient must be between the ages of 18 and 39. If the patient’s age is in another category, a different preventive medicine code should be used.

Confirm New Patient Status

Review applicable previous professional services when determining whether the patient qualifies as new. This step is especially important when the patient has previously received care from the same physician or group.

Confirm Preventive Purpose

The encounter should represent an initial comprehensive preventive evaluation. A problem-focused visit should not be reported as 99385 merely because the patient also received some preventive advice.

Review Additional Services

Laboratory testing, immunizations, screenings, procedures, and separately identifiable problem-oriented services should be reviewed individually. Each service may have its own reporting, documentation, coverage, and medical necessity requirements.

Verify Payer Requirements

Commercial insurers can establish different preventive coverage, frequency, eligibility, and cost-sharing requirements. Practices should verify the patient’s benefits and current payer policy whenever possible before submitting the claim.

99385 CPT Code Reimbursement

There is no single, national 99385 CPT reimbursement amount for all payers. Depending upon the insurance plan, the geographic region where the provider is located, the provider’s participation in the plan, the contract terms, the design of the preventive benefits, frequency limits, and the individual insurance plan policies, payment may differ.

Commercial plans may provide preventive benefits under different rules. A service that is covered without patient cost sharing under one plan may have different requirements under another plan, particularly when the service falls outside the plan’s defined preventive coverage.

For this reason, practices should avoid publishing one fixed reimbursement figure as though it applies universally. The appropriate approach is to verify the patient’s benefits and the payer’s current reimbursement policy for the specific date of service.

99385 and Medicare

Medicare is considered separately, since regular physical checkups are usually not covered as Medicare benefits. CMS categorizes routine physical exams as a different type of preventive service from more specific preventive services for which Medicare will reimburse under specific eligibility and billing criteria.

Medicare beneficiaries may be eligible for services like the Initial Preventive Physical Examination and Annual Wellness Visit. These services come with different requirements and HCPCS codes, and should not simply be replaced with coding HCPCS 99385.

Medicare Preventive Service Codes

CMS clarifies the Initial Preventive Physical Examination is a particular Medicare preventive service. The Annual Wellness Visit is also different from a regular physical exam and includes new eligibility and documentation guidelines. Therefore, practices should determine which Medicare preventive service applies before submitting a claim. Medicare coverage rules should always be reviewed against the current requirements for the date of service.

99385 and Medicare Wellness Visits

Do not view a Medicare Wellness Visit as a “comprehensive preventive physical. The Annual Wellness Visit consists of a health risk assessment and creation or revision of a personalized prevention plan. But the Initial Preventive Physical Examination has its own Medicare criteria.

This is important because the CPT preventive medicine codes and Medicare HCPCS wellness codes for preventive medicine have different uses. Before choosing the code, the coder should check the patient’s Medicare eligibility, service history and applicable coverage requirements.

Diagnosis Coding for 99385 Cpt code

The diagnosis code should precisely identify the preventive encounter and include an accurate description of any conditions diagnosed or addressed during the visit. When an examination is performed on an adult, the code Z00.00 for an examination performed without any abnormal findings. Z00.01 is likely to be coded for an examination performed with abnormal findings, unless documented otherwise.

The presence of an abnormal finding should be reflected appropriately in the diagnosis coding. Additional diagnoses may also be reported when conditions are evaluated, addressed, or otherwise supported by the documentation.

99385 Cpt code and Laboratory Services

Laboratory testing may be ordered during a preventive visit when appropriate for the patient’s health status, risk factors, and preventive needs. When a laboratory service is separately reportable, the applicable CPT or HCPCS code should be assigned rather than assuming the testing is represented entirely by 99385. Medical necessity and payer coverage should also be reviewed for each laboratory service. A test being ordered during a preventive visit does not automatically guarantee coverage by the patient’s insurer.

99385 Cpt code and Immunizations

Immunizations can also be provided during a preventive encounter. When separately reportable, the vaccine product and administration services should be coded using the appropriate CPT or HCPCS codes. The preventive medicine code does not automatically replace vaccine product or administration coding. Coding staff should verify current code definitions and payer requirements for the specific vaccine and administration service.

Common 99385 CPT Code Denials

Several issues can lead to denials involving 99385. Reviewing these issues before claim submission can help practices identify problems related to patient status, age, coverage, documentation, diagnosis coding, and modifiers.

Incorrect Patient Status

A payer may determine that the patient does not qualify as new based on previous professional services. This can occur when historical records are incomplete or when registration information is used without reviewing applicable coding rules.

Incorrect Age

99385 Cpt code applies to patients aged 18 through 39 years. A patient outside this range should be reported using the preventive medicine code corresponding to the patient’s age and patient status.

Frequency Limitation

Some insurance plans restrict preventive services based on frequency or benefit design. A claim can therefore deny even when the service itself was correctly coded if the patient’s benefit does not allow the service at that time.

Medicare Non-Coverage

Medicare generally does not cover routine physical examinations as a standard Medicare benefit. Medicare instead provides specific preventive services with separate eligibility and coding requirements.

Insufficient Documentation

A claim can face review when the medical record does not demonstrate the comprehensive preventive service reported. Missing examination findings, unclear counseling documentation, or incomplete preventive assessment can create support problems.

Modifier Errors

A claim edit or denial can result from the wrong modifier or a modifier that is not supported. Modifier 25 is not intended for use when there is no separate E/M service performed in addition to services provided as a part of a primary service.

Diagnosis Mismatch

The diagnosis coding should correspond to the documented preventive encounter and findings. Using a diagnosis that does not accurately reflect the record can create medical necessity or claim-processing issues.

How to Reduce 99385 Cpt code Denials

A consistent pre-billing review can prevent many avoidable errors. Coding staff should verify the patient’s age and status first, then review whether the documentation supports the preventive service and whether the payer covers the service under the patient’s benefits.

Use the following checklist:

• Verify patient age.
• Confirm new patient status.
• Check insurance eligibility.
• Review preventive benefit frequency.
• Confirm network participation.
• Review preventive documentation.
• Verify diagnosis coding.
• Review separately reportable services.
• Check modifier requirements.
• Review payer-specific preventive policies.
• Confirm Medicare coverage requirements when applicable.

This process helps distinguish coding problems from payer benefit limitations. It also gives the practice a consistent method for reviewing preventive claims before submission.

99385 CPT Code Examples

Example 1: New Patient Preventive Visit

A 24 year old patient comes in for a complete preventive exam with a family medicine provider. The provider conducts the appropriate preventive history and exam, discusses the health risks, offers preventive counseling, and offers appropriate screening recommendations.

Likely code: 99385

The medical record should support the patient’s age, new patient status, and comprehensive preventive service.

Example 2: Established Patient

A 31 year-old patient visits the practice for a routine preventive check-up. Patient seen by the practice at another time and therefore not a new patient.

99385 would not be appropriate.

When the encounter meets the requirements, 99395 would generally be considered for the established patient’s periodic preventive service.

Example 3: Patient Aged 42

A new patient aged 42 has a comprehensive preventive exam. The patient is a new patient, but the patient’s age is not in the range of 18-39 years needed to code 99385.

When a preventive medicine code applies, 99386 is usually the code that will be used for a new patient between the ages of 40 and 64 who receives preventive medicine services.

99385 Coding Audit Checklist

The following questions may be helpful for conducting a coding audit and determining if the claim is supported.

Key Takeaways

CPT 99385 codes for an initial comprehensive assessment for a new patient, ages 18-39, for a comprehensive periodic evaluation of preventive medicine. However, simply confirming the patient was seen for a physical is not enough to ensure accurate reporting and patient status, preventive intent, documentation and payer-specific coverage must also be verified.

The most important points are:

• 99385 applies to new patients aged 18 through 39.
• It represents an initial comprehensive preventive service.
• It is not selected using MDM.
• It is not selected using a specific time threshold.
• Preventive counseling can be part of the service.
• Separately reportable laboratory and diagnostic services should be coded individually.
• 99395 generally applies to established patients in the same age range.
• 99204 represents a different, problem-oriented E/M service.
• Modifier 25 may apply when a separate E/M service is significant and separately identifiable.
• Medicare routine physical examinations have different coverage rules.
• Medicare wellness services use separate HCPCS codes.
• Diagnosis coding should reflect the documented examination and findings.
• Payer-specific preventive coverage should be verified before billing.

Patient age, status, and documented service, diagnosis coding, and the requirements of various payers must all be matched to get 99385 CPT codes right. A careful review before claim submission can help minimize the incorrect code selection, modifier problems, documentation issues and denials that can be avoided.

Frequently Asked Questions