99385 CPT Code in 2026: Age Limit, Reimbursement, and Billing Rules

What is the 99385 CPT code?

The 99385 CPT code covers a comprehensive preventive medicine visit for a new patient aged 18 to 39. It applies only when the patient has not been seen by the practice or a same-specialty provider in the same group within the past three years. Traditional Medicare does not cover 99385, so Medicare patients use G0402, G0438, or G0439 instead.

Age limit: The patient must be 18 to 39 years old on the date of service, not the scheduling date.

Reimbursement: Commercial and ACA plans typically pay about $150 to $220, while traditional Medicare does not cover it.

Same-day billing: A separate problem visit like 99203 or 99204 can be billed alongside it with modifier 25 on the problem code.

What is the 99385 CPT code age limit?

The 99385 age limit is 18 to 39 years, measured by the patient’s age on the date of service rather than when the appointment was booked. A patient who has turned 40 before the visit moves to 99386, and a patient under 18 uses 99384. The code also applies only to new patients, meaning someone who has not received professional services from the practice or a same-specialty provider in the same group within the past three years.

The three-year window is where most of the confusion lives. A patient who visited the practice three years and one day ago qualifies as new. A patient who saw a different specialty within the same group, such as a dermatologist in a multi-specialty clinic when the preventive visit is with the internist, still qualifies as new because the specialties differ. But a patient who saw another provider of the same specialty in the same tax ID within three years is established and should be billed under 99395 instead.

The full preventive medicine family is organized by age and patient status, so picking the right code is a two-step check. Use this table to confirm the match.

CPT is a registered trademark of the American Medical Association. Confirm the patient’s age and new-versus-established status at the date of service, not at scheduling.

In our experience matching providers with billing partners, age-band errors on preventive codes are one of the most common reasons for clean claim rate drops among practices that see a high volume of young adults. A patient who turns 40 between scheduling and the visit date is the classic example: the scheduler books the appointment under 99385, the provider documents the exam, and the claim goes out coded to the wrong age band. By the time the denial comes back, the practice has already billed the patient incorrectly. Checking age at the date of service, not at scheduling, prevents this entirely.

What is the 99385 CPT code reimbursement in 2026?

Commercial and ACA plans typically reimburse 99385 at roughly $150 to $220, and because it is a preventive service, most plans cover it first-dollar with no patient copay or deductible under the Affordable Care Act. Rates vary by payer, region, and contract year, so verify the specific plan’s fee schedule before assuming a set reimbursement level.

Traditional Medicare does not cover 99385 at all, because routine preventive physicals are a statutory exclusion. For Medicare patients, bill G0402 for the Welcome to Medicare visit, G0438 for an initial Annual Wellness Visit, or G0439 for a subsequent one. Submitting 99385 to Medicare returns a non-covered denial, and Medicaid coverage varies by state program, so confirm eligibility before scheduling.

One pattern we see providers run into repeatedly is confusing the Annual Wellness Visit with a comprehensive preventive physical. The AWV (G0438 and G0439) is a health risk assessment, not a head-to-toe exam. It does not include a full physical examination the way 99385 does. A provider who performs a full preventive exam on a Medicare patient and bills G0438 thinking it is the Medicare equivalent of 99385 is misrepresenting the service. The documentation must match what was actually performed, and the code must match the documentation.

For commercial payers, the ACA preventive mandate means the insurer cannot apply cost sharing to services rated A or B by the U.S. Preventive Services Task Force. That typically includes the preventive visit itself, along with recommended screenings performed during it. However, the moment a provider addresses a separate clinical problem during the same encounter, the problem-oriented portion falls outside the ACA mandate and is subject to the patient’s normal cost sharing. Practices that do not explain this distinction at the front desk generate patient complaints and collections issues downstream.

Can you bill 99385 and a problem visit (99203 or 99204) together?

Yes, when a significant, separately identifiable problem is addressed during the same visit. Report the preventive code 99385 and the problem-oriented office visit together, with modifier 25 appended to the problem code, such as 99203-25 or 99204-25, never to 99385. Select the problem visit level by medical decision making, since time spent on the preventive service cannot count toward it.

The documentation has to clearly separate the two services. Counseling that is part of a wellness exam, such as diet or tobacco advice, stays inside 99385. A distinct new complaint, such as knee pain, a urinary tract infection, or a skin lesion that the provider evaluates and treats, supports the separate problem visit. One important patient-experience note: the preventive portion is covered first-dollar, but the problem-oriented portion may be subject to the patient’s normal copay or deductible.

The most common mistake we see across billing companies we vet is placing modifier 25 on the wrong code. Modifier 25 goes on the E/M problem visit, not on the preventive service. When a biller appends it to 99385 instead of 99203 or 99204, the payer either denies the problem visit outright or pays the preventive visit at a reduced rate because the modifier signals that 99385 itself was the add-on service. Either way, the practice loses revenue on a claim that should have been straightforward.

Choosing between 99203 and 99204 depends entirely on the medical decision making required by the separate problem. A simple UTI with a straightforward antibiotic prescription typically supports 99203-level MDM. A skin lesion requiring biopsy, differential diagnosis, and a follow-up plan supports 99204. The provider’s note must document the MDM elements for the problem independently from the preventive exam, and the time spent on the preventive service cannot be counted toward the problem visit level. These are two distinct services happening in one encounter, and the documentation must read that way.

What is the difference between 99385 and 99395?

Both 99385 and 99395 cover a comprehensive preventive medicine visit for a patient aged 18 to 39. The only difference is patient status: 99385 is for a new patient, and 99395 is for an established patient who has been seen by the practice or a same-specialty provider in the same group within the past three years. The clinical service is the same comprehensive exam, but the reimbursement rates differ because payers recognize higher work associated with a new patient encounter.

The three-year rule creates gray areas that trip up billing staff. A patient who has seen only a nurse practitioner in the group but not a physician of the same specialty may or may not qualify as established, depending on how the group’s credentialing and taxonomy codes are structured. A patient who moved away, saw other providers for four years, and returns to the same practice qualifies as new again. The safest approach is to check the practice management system for the last face-to-face professional service date with any provider of the same specialty and same group NPI before selecting the code.

One question we hear constantly from practice managers is why their new patient preventive visits keep getting denied. When we look at the data, the issue is almost always a 99385 billed for a patient who is actually established. The front desk books them as new because the patient says they have never been there, but the system shows a visit 18 months ago with a different provider in the same specialty group. That single lookup prevents the denial and the rework.

The 99385 billing mistakes that cause denials

Preventive claims are among the most audited in outpatient care, and the denials cluster around a few predictable errors. Work through these before the claim goes out.

• Confirm new patient status: use 99385 only when the patient has not been seen by the practice or same-specialty group in three years, otherwise use 99395.
• Check the age at the date of service: bill 99385 only for patients 18 to 39, moving to 99384 or 99386 outside that band.
• Route Medicare patients to the right code: use G0402, G0438, or G0439 rather than 99385, which Medicare does not cover.
• Add modifier 25 to the problem visit: append it to 99203 or 99204, never to 99385, when a separate problem is treated the same day.
• Pair the correct diagnosis: report Z00.00 for a normal exam or Z00.01 when abnormal findings are documented. For visits involving dehydration workups or other acute complaints, link the appropriate ICD-10 code to the problem visit, not to 99385.
• Bill vaccines and labs separately: report immunizations and screening tests with their own CPT codes rather than folding them into 99385. Each vaccine administration and each lab draw has its own billable code, and bundling them into the preventive visit leaves revenue on the table.
• Verify frequency limits: confirm the payer’s preventive visit interval before scheduling to avoid a duplicate-service denial. Most commercial plans allow one preventive visit per benefit year, but some define the interval as 365 days from the last visit rather than by calendar year.

Because young adults often visit urgent care for sports, school, and employment physicals, a single recurring error, such as misrouting a Medicaid patient or dropping modifier 25, multiplies fast across a busy schedule. Fixing it at the front end is where experienced urgent care medical billing support pays for itself. Providers often come to us after a quarter of denied preventive claims, and the root cause is usually one of the seven errors above repeated across dozens of encounters.

How 99385 works in urgent care settings

Urgent care clinics see a disproportionate share of 99385-eligible visits because they attract young adults who need physicals for sports clearance, college enrollment, pre-employment screening, and insurance wellness requirements. Many of these patients do not have an established primary care provider, which makes them new patients by definition and puts 99385 squarely in play.

The billing challenge unique to urgent care is that these visits frequently include a separate acute complaint. A 22-year-old comes in for a sports physical and mentions a sore throat. A 30-year-old needs a pre-employment exam and asks about a persistent rash. In each case, the provider performs both the comprehensive preventive exam and an evaluation of the separate problem. When the documentation supports it, the clinic can bill 99385 for the preventive service and the appropriate E/M code with modifier 25 for the problem, capturing both revenue streams from a single encounter.

The risk is that the documentation does not clearly separate the two services. In a fast-paced urgent care environment, providers often document the entire visit in one continuous note rather than splitting it into a preventive section and a problem-oriented section. When the note reads as a single narrative, the payer cannot distinguish the preventive work from the problem work, and the modifier 25 claim gets denied. The fix is a documentation template that physically separates the preventive exam findings from the problem-oriented history, exam, and medical decision making. Across the billing companies we vet, the ones that perform best on urgent care preventive claims all enforce this split-note structure at the template level rather than relying on providers to remember it.

Frequently Asked Questions

Bill preventive visits cleanly and collect first-dollar

The 99385 code rewards front-end discipline: verify new patient status, check the age at the date of service, route Medicare patients to the right G-code, and reserve modifier 25 for a genuinely separate problem. Handled that way, preventive visits are among the cleanest claims a practice files. Handled loosely, they are among the most denied. That difference is exactly what a strong billing team manages, and it is the difference between a preventive visit that pays cleanly at $150 to $220 and one that generates a denial, a rework cycle, and a confused patient who received a bill they were told would be free.