CPT Code 99396: Preventive Visit, Established Patient 40-64

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• 99396

CPT Code 99396: Preventive Visit, Established Patient 40-64

99396 for established patients 40-64 — what it covers, why Medicare pays G0438/G0439 instead, same-day E/M with modifier 25, and BH screening add-ons.

Quick Reference

Code

99396

Code System

CPT

Category

CPT Codes

Published

Jun 11, 2026

Reading Time

12 min

CPT® is a registered trademark of the American Medical Association. All CPT code descriptions on this page are paraphrased in original wording; consult the current CPT® codebook published by the AMA for authoritative descriptors.

Understanding CPT Code 99396: Adult Preventive Visit (Established Patient, 40-64)

CPT code 99396 reports a periodic comprehensive preventive medicine evaluation for an established patient age 40 through 64. Unlike the problem-oriented office visit codes ( 99212 – 99215 ), 99396 is not about evaluating a complaint — it covers the scheduled “annual physical” style encounter: a comprehensive age-appropriate history and exam, counseling on health risks and prevention, and orders for the screenings and immunizations the patient is due for.

For behavioral health organizations, 99396 matters in one specific context: integrated, whole-person care. CCBHCs, opioid treatment programs with primary-care integration, and behavioral health clinics employing or contracting primary-care providers increasingly deliver preventive visits in-house — and preventive visits are also the natural vehicle for the behavioral health screening codes covered below. This guide explains the code family, the two perennial billing confusions (Medicare’s non-coverage, and same-day problem visits), and the screening services that ride along.

Definition and Purpose

99396 describes the established-patient preventive visit for the 40–64 age band: a comprehensive evaluation oriented to health maintenance rather than to a presenting problem. The visit has three working parts: a thorough history and physical exam scaled to the patient’s age and sex; time spent counseling the patient about health risks, habits worth changing, and what to expect in the decade ahead; and orders for whatever screening labs and diagnostic studies fit the patient’s age and risk profile.

“Comprehensive” here is not the same as the old E/M comprehensive exam levels — the preventive codes were never part of the 2021 office-visit E/M overhaul, and they have no MDM or time thresholds. Level selection within the preventive family is by age and new/established status only.

The Preventive Code Family (99381–99397)

A single table covers the whole family. 99396 is the established 40–64 row.

The new/established distinction follows the standard CPT rule: a patient is established if they received a professional service from the provider (or another provider of the same specialty in the same group) within the past three years.

99396 vs Medicare Wellness Visits (G0438/G0439)

This is the most consequential fact on this page: traditional Medicare does not pay 99396 — or any of the 99381–99397 preventive codes. Routine physical examinations are statutorily excluded from Medicare coverage. Billing 99396 to Medicare produces an automatic denial. Because the denial rests on a statutory exclusion — not on medical necessity — a mandatory ABN is not required before billing the patient: the patient is financially responsible for the non-covered physical, and a voluntary ABN serves only as a courtesy notice of that liability.

Medicare patients instead receive Medicare’s own wellness benefit structure:

Note that the AWV is not a physical exam — it is a health-risk-assessment and prevention-planning service. A practice that performs a hands-on comprehensive physical for a Medicare patient is performing a service Medicare does not cover, regardless of which code is attempted.

Who does pay 99396: commercial plans and many state Medicaid programs. Under the ACA’s preventive-services mandate, non-grandfathered commercial plans cover preventive visits without patient cost-sharing when delivered in-network and billed as preventive. Some Medicare Advantage plans also pay 99396/99397 as a supplemental “annual physical” benefit alongside the AWV — plan-by-plan verification is required.

Preventive + Problem-Oriented E/M on the Same Day (Modifier 25)

The second perennial confusion: the patient comes in for their preventive visit and says, “while I’m here, my anxiety has been much worse.” When a significant, separately identifiable problem is evaluated and managed during a preventive encounter, CPT permits reporting both the preventive code (99396) and a problem-oriented E/M ( 99213 or 99214, as supported) with modifier 25 appended to the problem-oriented code.

Requirements that make the combination defensible:

Some payers bundle or reduce payment on the problem E/M when billed with a preventive visit even with modifier 25 — check payer-specific policy.

• The problem work must be significant. Incidental mention of a stable, managed condition that requires no additional work does not justify a second E/M. New complaints, worsening conditions, or anything requiring its own assessment and plan does.
• Documentation separation. The note should make the two services independently visible: the preventive components (history, exam, counseling, screening orders) and, distinctly, the problem-focused assessment and plan. The problem E/M level is selected on its own merits — MDM or time attributable to the problem work alone.
• No double-dipping. The same history and exam elements cannot count toward both services; the problem E/M must stand on work beyond the preventive visit’s scope.
• Warn the patient about cost-sharing. This combination is the classic “surprise bill” scenario: the preventive portion processes at $0 cost-share under ACA rules, but the modifier-25 problem visit is a regular medical claim that hits the deductible or copay. A patient who scheduled “a free physical” and receives a bill is a complaint waiting to happen — front-desk and provider scripts should set the expectation at the time of service.

Behavioral Health Screening During Preventive Visits

This is where 99396 connects directly to behavioral health operations. Preventive visits are the natural delivery point for USPSTF-recommended behavioral health screenings — and for integrated-care organizations and CCBHCs, these add-on codes are revenue and quality-measure infrastructure.

Depression screening. USPSTF recommends screening all adults for depression. With a standardized instrument (e.g., PHQ-9), report 96127 (brief emotional/behavioral assessment with scoring) per instrument — commercial and many Medicaid payers reimburse it alongside preventive visits, though some bundle it. In the Medicare AWV context, the parallel service is G0444 (annual depression screening, subsequent AWVs) — not applicable to 99396 itself since Medicare doesn’t pay 99396, but relevant for the same clinic’s Medicare panel.

Alcohol and substance use screening / SBIRT. Structured screening and brief intervention services have three parallel code sets by payer type: CPT 99408 (15–30 minutes) and 99409 (over 30 minutes) for commercial payers; G0396/G0397 for Medicare; and H0049/H0050 in many state Medicaid programs. For a behavioral health organization running preventive visits, SBIRT during the 99396 encounter is both clinically aligned and separately billable when time and documentation thresholds are met.

Tobacco cessation counseling. 99406 (3–10 minutes) and 99407 (over 10 minutes) are reportable in addition to a preventive visit when a tobacco user receives dedicated cessation counseling beyond the visit’s general anticipatory guidance, with the counseling time documented separately.

Bundling caution. Brief, generic lifestyle counseling is included in the preventive visit; the add-on codes require distinct, documented services meeting each code’s own elements (instrument + scoring for 96127; minimum minutes for SBIRT and tobacco codes). When in doubt, check the NCCI edit pair and whether a modifier (typically 25 or 59, per payer instruction) is required and supportable.

For organizations whose mission is whole-person care, this stack — 99396 + screening codes — is how the preventive visit funds integrated behavioral health screening rather than absorbing it. ’s EHR for integrated behavioral health administers instruments like the PHQ-9 and GAD-7 in-app and auto-scores them on submission, so the documentation side is captured discretely rather than rekeyed.

Documentation Requirements

A 99396 note should demonstrate the preventive character of the visit:

What distinguishes preventive documentation from a problem visit: the record is organized around health maintenance and risk reduction, not around a chief complaint, and there is no problem-driven MDM unless a separately reported E/M occurred.

• Comprehensive age-appropriate history — past medical, family, and social history; review of systems; current medications and allergies; update since the last preventive visit.
• Comprehensive age-appropriate examination — a multisystem preventive exam, not a problem-focused exam.
• Risk-factor identification and counseling — tobacco, alcohol and substance use, diet and activity, sexual health, safety, and mental health; anticipatory guidance appropriate to a 40–64-year-old patient.
• Screening and immunization orders — age- and risk-appropriate orders (e.g., colorectal cancer screening, lipid panel, mammography referral, immunization updates) with USPSTF-aligned rationale.
• Distinct documentation for any add-on services — screening instruments with scores, SBIRT or tobacco counseling time, and any modifier-25 problem E/M as its own assessment/plan.

Billing and Reimbursement

There is no Medicare national fee schedule rate for 99396 — Medicare does not cover the code, so unlike the office-visit E/M codes there is no PFS benchmark to quote. Reimbursement is set by commercial contracts and state Medicaid fee schedules, and varies widely by market and contract; check your payer fee schedules rather than relying on national averages.

Billing mechanics:

• ICD-10 pairing: report Z00.00 (general adult medical examination without abnormal findings) or Z00.01 (with abnormal findings) as the primary diagnosis. When abnormal findings are addressed as a separate E/M, the specific condition codes accompany the modifier-25 claim line.
• Medicaid: coverage of adult preventive visits varies by state — some states cover 99381–99397, others use alternative codes or limit frequency. Verify the state fee schedule.
• Frequency: most payers cover one preventive visit per calendar year; some apply a 365-day rule (a full year since the last preventive visit). Denials from scheduling the “annual physical” 11 months apart are common under 365-day rules — know which rule each major payer applies.

Common Modifiers

• Modifier 25 — appended to the problem-oriented E/M (not to 99396) when a significant, separately identifiable problem service is performed the same day.
• Modifier 33 — preventive service: signals that a service is ACA-mandated preventive care and should process without cost-sharing. Generally unnecessary on 99396 itself (inherently preventive) but used on services that can be either preventive or diagnostic.
• Telehealth modifiers (95/93) — generally not applicable: a comprehensive preventive visit requires a hands-on examination, and payers do not typically recognize 99381–99397 via telehealth.

Compliance Considerations

• Billing 99396 to traditional Medicare — automatic denial; route Medicare patients to the AWV workflow (G0438/G0439). If the patient requests a non-covered physical anyway, a voluntary ABN is good practice as a courtesy cost notice — but because routine physicals are statutorily excluded, the patient owes the charge with or without one.
• Double-dipping preventive and problem documentation — using the same history/exam work to support both 99396 and a modifier-25 E/M is the primary audit finding in this code family. The problem E/M must be independently supported.
• Frequency denials — one per calendar year vs. 365-day rules vary by payer; build the rule into scheduling, not just billing.
• Age-band errors — a patient who turned 65 belongs at 99397 (and may now be Medicare-primary, changing the entire coverage analysis).
• Screening add-on documentation — each add-on (96127, SBIRT, tobacco) must meet its own elements; appending screening codes without instruments, scores, or time documentation invites recoupment.

Sources

This guide is for general billing education and is not legal or payer-specific advice. CPT® is a registered trademark of the American Medical Association; code descriptions here are original-language summaries, not AMA descriptor text.

• CMS MLN: Medicare Preventive Services educational tool ↗ — Medicare coverage map and G-codes
• CMS MLN: Annual Wellness Visit booklet ↗ — G0438/G0439 requirements
• CMS: NCCI Policy Manual ↗ — preventive + E/M same-day and screening-code edits
• USPSTF: A and B recommendations ↗ — which screenings accompany preventive visits
• ICD-10-CM Official Guidelines ↗ — Z00 encounter coding

Related Billing Codes

• 99215
• 99354
• 99355
• 99406
• 99407
• 99408

Reference tables

Common questions

Official sources

• CMS MLN: Medicare Preventive Services educational toolcms.gov
• CMS MLN: Annual Wellness Visit bookletcms.gov
• CMS: NCCI Policy Manualcms.gov
• ICD-10-CM Official Guidelinescms.gov