Rendered medical services are billed in the form of medical codes. These codes specify the diagnoses, treatment, and patient care services. Such codes are of different types, and Current Procedural Terminology (CPT) codes hold a significant place in the coding system. Services during office visits, outpatient departments, or emergencies are all covered by CPT codes. CPT code 99395 refers to the preventive services for the well-being of established patients. Accurate assignment of codes is necessary for claim acceptance and timely reimbursement.
In this article, we will discuss the 99395 CPT code description, its significance in healthcare, and the various services covered under this code.
99395 CPT Code Description
Before diving deep into the discussion, it is important to learn the basic concept and understanding of the 99395 code. This code bills for preventive medical services rendered to adult patients. This code applies to established patients who come for office visits. Accuracy in writing codes, documentation compiling, and use of modifiers is necessary for claim submission.
All services related to preventive care are billed under this code. This code covers detailed medical history, detailed medical examination, counseling on risk factors, screening tests, and immunizations. Problem-focused visits are not applied here. CPT code 99395 only deals with preventive care for annual visits, which are termed wellness visits.
99395 has an important role in the wellness of society as a whole. Early screening of contagious diseases can prevent the outbreak. Overall, mortality and morbidity rates are reduced by early detection and treatment. A healthy lifestyle is promoted with counseling, which leads to a healthy society.
What Is CPT Code 99395 Used For?
The following are the details of all services covered under this code. The details of each service help the provider better understand the nature of this code.
1. Detailed Medical History
As it is not problem-focused, there will be no symptoms to describe from the patient’s side. Providers need to ask medical questions and try to find any potential findings in medical history using their experience. Detailed medical history of lifestyle, diet, and past illnesses is assessed, and modifications are advised to patients. Family history is very important in understanding the pattern of any chronic disease in the family. For example, a family history of breast cancer allows for BRCA gene mutation screening and conservative mastectomy in risky patients.
Drug history, smoking history, and information about the profession also help in determining the risk factors and making suitable screening plans.
2. Detailed Medical Examination
After a medical history, a medical examination comes into action. It starts with checking vital signs like temperature, blood pressure, heart rate, and respiratory rate. Assessment of BMI is also necessary for making an accurate diet plan and knowing the current nutritional state of the body.
A complete examination of each system of the body helps to evaluate its working condition. In case of any abnormal findings, they are documented and aligned with history to make a diagnosis. Abnormalities also help to select a screening test for further evaluation.
3. Risk Factor Counselling
Risk factors are determined by history and examination, which helps to make changes in lifestyle for patient wellness. Smoking cessation is advised, and diet plans, i.e., junk food and excess carbohydrate intake, are avoided. Protein-rich diet and exercise are advised. In case of any specific risk factor, counseling is the best option. Healthcare providers also provide stress management and mental health support to patients.
4. Immunization And Laboratory Tests
As per guidelines of the patient’s risk profile, immunization and laboratory tests are recommended. Such services are also covered under the 99395 CPT code. Laboratory tests help in screening, diagnosis, and detection of asymptomatic ailments.
5. 99395 CPT Code Description Age Limit
Age limit is also important for billing 99395. It is usually used for adults between the ages of 18 and 39 years. 99395 CPT code age should be considered important in this regard because billing the same code for other ages leads to claim denial or rejection, resulting in a potential revenue leak.
Billing Considerations for CPT Code 99395
Insurance Coverage
There are many insurance companies, such as private payers, Medicare, and Medicaid, that have specific requirements for preventive services. It is important for the providers to have a thorough understanding of each insurance requirement before starting the medical services. Insurance coverage should be checked to determine whether the 99395 code can be billed or not.
Documentation Requirements
Documentation is considered the cornerstone of medical billing and coding. It is also important to undergo internal and external audits successfully. A complete description of medical services, including patient presentation, medical history, examination, and management plan, is noted. Documentation helps to justify the use of the 99395 CPT code in the medical bills.
Modifier Use
Modifier use is necessary for accurate medical billing and timely reimbursement. If additional services are provided during the preventive visits, then there is no need for a separate medical bill. Such additional services are covered under the same bill with the use of modifiers.
For example, if a patient presents with acute abdomen or urinary problems during the preventive visit, then the provider needs to use the modifier -25 along with CPT code 99395 for billing additional services.
Frequency of Visits
Insurance payers like Medicare and Medicaid have put limitations on the number of annual visits. Only one annual preventive visit is allowed for adult patients. Additional visits result in claim denial. A second visit can be allowed if necessary, but a detailed report of medical necessity is sent to the payer for permission. Pre-authorization is necessary for additional preventive visits.
Coding For Immunization/Laboratory Services
During preventive visits, decisions for immunization or laboratory tests can be made, but these services are billed under additional codes. 99395 CPT code description explains that further lab services can be ordered under this code but billed separately.
- If a seasonal flu vaccination is ordered during these visits, then the administration of the vaccine is billed another 90680 CPT code. This needs separate documentation and separate billing.
- The same is the case with laboratory tests; they are also billed separately. Lab tests like urine analysis, CBC, LFTs, RFTs, and imaging tests are assigned specific CPT codes.
- CPT code 90832 bills for additional services. Diagnostic tests bill under code 81000.
Medicare Guidelines
Medicare is the main payer that plays a significant role in patient wellness. The Medicare program does not cover all preventive services. Medicare is very strict in billing preventive CPT codes. Providers need to remain vigilant and careful while billing Medicare for preventive visits. Documentation and billing should align with the Medicare guidelines. Medicare covers some preventive services. The details of services are below:
- Annual Wellness Visits: One visit is allowed annually as per guidelines. 99395 CPT code description age limit is 18-39.
- Mammogram Screening: Every 12-24 months, a mammogram screening test is allowed in high-risk patients.
- Colonoscopy: It is allowed every 10 years in risky patients having a family history of colon cancer or FAP disease.
- Flu Vaccine: It is done once per year.
- Bone Density Test: This test requires pre-authorization and is only performed in high-risk patients.
- Counseling Services: Tobacco cessation, diet plan, mental health support.
These are various services that are covered by Medicare. Maintain documentation, medical necessity reports, and accurate medical bills to get reimbursements on time. Medicare has a large patient base but low reimbursement rates. Providers who want to grow financially and can handle a maximum number of patients should contract with Medicare.
Conclusion
CPT code 99395 refers to preventive medical services for established patients between the ages of 18 and 39 years. What is CPT code 99395 used for? It is used for screening purposes and the wellness of the patients. It covers detailed medical history, examination, counseling on risk factors, and ordering laboratory tests. Lab tests and immunization services are billed separately, but the decision to use these services comes under 99395. A few billing considerations should be kept in mind while billing for 99395. Insurance coverage is checked as a primary thing.
Only insured patients a re allowed to get preventive services. Documentation is very necessary for claim submission and acceptance. One visit per year is allowed in the preventive 99395 code. In case of medical necessity for further visits, pre-authorization is required. Providers need to comply with Medicare billing guidelines for the 99395 CPT code to avoid claim denial. Medical billers should have a thorough understanding of every billing guideline to enhance the efficiency of billing operations.
FAQ - People Also Asks
Modifier -25 is used with CPT code 99395 to cover additional services. If a patient presents with any symptoms like an infection or ulcer during the preventive management visits, then the use of a modifier is necessary to bill for additional patient care.
Immunizations ordered under CPT code 99395 are billed separately. 90471 is the Current Procedural Terminology (CPT) code, which is used to bill the vaccine administration services. Accurate documentation and regulatory compliance are vital for timely reimbursement.
For now, CPT code 99305 is being used for in-person office visits. For billing telemedicine preventive visits, providers need to go through the payer’s specific policies.
No, this code cannot be used for new patient visits. Established patient office visits for preventive care are only billed under 99395. For new patients, another code, 99385, is used.