CPT codes are essential for streamlining communication between healthcare providers, patients, and payers, ensuring accurate billing and reimbursement. Among these, CPT Code 99396 is a preventive care code specifically used for comprehensive wellness visits. This code, tailored to a specific age group, is vital for documenting and billing annual preventive services accurately.
Whether you’re a medical biller, healthcare provider, or patient seeking clarity, understanding the age limits, description, and billing requirements of CPT Code 99396 is crucial. This article delves into the details of what CPT Code 99396 represents, its billing guidelines, and common challenges medical professionals face when submitting claims.
In this article, we will discuss what does CPT code 99396 stand for? We will also learn numerous billing considerations and challenges faced by medical billers.
99396 CPT Code Description: Everything You Need to Know
CPT code 99396 refers to preventive evaluation and management services for established patients aged 40-64. These visits focus on routine checkups and screenings rather than addressing specific medical complaints. Understanding the CPT code 99396 age limit and patient type is crucial for accurate billing and claims submission.
Preventive care is especially vital for patients in this age group, who may be at higher risk for conditions like hypertension, diabetes, or cancer. Regular screenings help detect diseases early, enabling timely intervention and improved outcomes.
What Does CPT Code 99396 Include?
99396 covers essential preventive care services, including medical history reviews, physical examinations, screenings, and counseling. Here’s a detailed breakdown:
Medical History
Patients present for routine checkups, not specific complaints. A detailed medical history is taken, including:
- Past Illnesses: Chronic diseases, surgeries, or interventions.
- Lifestyle Factors: Drug, smoking, and travel history to identify risk factors.
- Family History: Genetic predispositions to chronic diseases or cancer.
Medical Examination
Physicians perform a detailed physical exam to assess overall health. This includes:
- Vital signs like pulse, blood pressure, BMI, and respiratory rate.
- Examination of each organ system for abnormalities.
- Documentation of findings for medical records and claim submissions.
CPT Code 99396 Age Limit
There are many CPT codes billing for preventive E/M visits, but each code refers to a different age group. As per the 99396 CPT code description, the age limit is 40-64. Age groups above or below this limit are billed by other codes.
Health Counseling
Healthcare providers offer personalized advice on maintaining a healthy lifestyle, covering topics like:
- Diet and exercise plans tailored to BMI and overall health.
- Smoking cessation, alcohol moderation, and mental health tips.
Preventive Screening and Immunizations
Routine screenings are vital for early detection of age-related conditions like:
- Hypertension, diabetes, high cholesterol, and cancer.
- Immunizations and BMI assessments to ensure optimal health.
- Health education to promote proactive care and awareness.
Why Is CPT Code 99396 Important?
This code ensures patients receive comprehensive preventive care while healthcare providers achieve accurate documentation and reimbursement. By understanding the 99396 CPT code description, medical billers can streamline the billing process, reduce claim denials, and enhance patient care quality.
Common Billing Challenges And Solutions
Billers and healthcare providers have to face many challenges like claim errors, overcoding, undercoding, coverage variations, compliance and other specific requirements.
It is hard for billers and providers to stay updated with new billing rules and regulations which can create hiccups in the billing process. Hiring expert billers equipped with the latest knowledge or collaborating with third-party service providers can make the billing process smooth and efficient. Cost reduction and less administrative burden are also benefits of this measure.
The medical billing process is prone to human errors like missing or incorrect information, which leads to claim denials. Billing software and auto-filling programs should be introduced in billing systems. The use of AI and technology can also help in real-time error detection. Such measures can be helpful in streamlining the billing process and decreasing claim denials.
To avoid billing errors, coding problems, and high expenses, it is advised that electronic health records in medical billing be streamlined and that billers be educated. With the use of such measures, a decrease in claim denials and an increase in revenue reduction has been seen in many healthcare facilities.
Billing and Reimbursement for CPT Code 99396
What is CPT code 99396, and what are its billing guidelines? Many healthcare providers ask this question. We will discuss all billing guidelines and reimbursement considerations in this guide.
Documentation Requirements
Documentation has always proved as a cornerstone in accurate medical billing and coding. It is necessary for the justification of medical claims. Providers can perform audits based on documentation. Every detail of medical history, examination, patient information, screening tests, and time of session is noted and saved as a health record. Without documentation, billing claims are rejected leading to financial losses.
Billing Limitations
What does CPT code 99396 include? It is important to know the inclusion and exclusion criteria for each billing code. For 99396, there are many limitations that should be kept in mind because billing for those extra services under 99396 can not be done. Rendering extra services and expecting payment will be just a waste of resources and time.
If tests like X-rays, CT scans, MRIs, or lab tests are recommended, then they will be billed separately. You can claim their payment in a single bill. Providers need to maintain separate documentation and submit claims for these services. In addition to this, more than one preventive visits need pre-authorization from payers in case of medical necessity.
Payer-Specific Guidelines
Each insurance payer has its own rules and regulations for billing CPT codes. Before getting involved in submitting claims, it is better to check the billing guidelines and act accordingly to avoid denials.
If we talk about Medicare, this program does not accept claims for the 99396 code. Medicare provides preventive care and screening opportunities through its Annual Wellness Visit (AWV). During these visits, medical assessment and screening are made for potential abnormalities. Physical examination of the body and each organ system is not involved in Medicare preventive visits.
Modifier Use
If a patient present with some medical problem during the preventive visits, then it is not recommended to submit two separate claims for preventive and problem-oriented visits. The single claim is submitted but using modifier 25. This modifier indicates that medical care for any symptoms, along with preventive E/M care, is rendered to the patients. Modifier use prevents undercoding or overcoding problems. Documentation should be maintained for all types of patient care services.
Conclusion
What is CPT code 99396? 99396 code refers to the medical services provided to established patients between the ages of 45-65 during preventive evaluation and management visits. It has components like medical history, examination, screening, and health counselling for detecting any abnormality.
The use of modifiers like 25 enhances the credibility of billing when other services are rendered during the same visit. Documentation and understanding of payer-specific guidelines also play a key role in billing operations. The use of technology and third-party service providers has also reduced administrative burdens and costs.
FAQ - People Also Asks
99213 CPT code is used for billing the regular problem-oriented office visits, while 99396 bills the preventive E/M visits. Both codes can be billed together but with the use of modifier 25. Modifier use indicates that additional medical services are given during the same preventive visit.
Preventive counselling to people to modify their lifestyle, medications, diet, and exercise routine can be billed using the CPT code 99401. This code does not include medical history, examination, or screening tests.
No, 99396 only bills for established patients. CPT code 99385 is used to bill the new patients for preventive E/M visits for the age limit of 45-64 years.
99396 CPT code is generally billed once in one year, but the frequency of preventive visits depends on the type of payer. For additional visits in case of medical necessity, pre-authorization from the payer is recommended for successful claim submission.
Under CPT code 99396, the services typically include:
- A detailed patient history and physical exam.
- Screening for conditions based on the patient’s age and gender (e.g., cholesterol, diabetes).
- Counselling on diet, exercise, and lifestyle.
- Preventive care discussions, such as immunizations or routine health screenings.
No, CPT Code 99396 is strictly for preventive care. Additional evaluation or diagnostic services may need a separate CPT code if a new or existing problem is addressed during the visit.
The main difference lies in the patient’s age and whether they are new or established:
- 99385: New patients aged 40–64
- 99386: New patients aged 65+
- 99396: Established patients aged 40–64
- 99397: Established patients aged 65+
No, CPT Code 99396 does not include laboratory tests. If lab tests are conducted, they are billed separately with their respective CPT codes.
Documentation for CPT code 99396 should include:
- A comprehensive patient history.
- Results of a physical exam.
- Counseling or anticipatory guidance provided.
- Recommendations for preventive screenings or interventions.