Summary & Overview
CPT 99386: Initial Preventive Medicine Evaluation for New Adult Patients
CPT code 99386 represents the initial comprehensive preventive medicine evaluation and management for new patients aged 40 to 64 years. This code is a cornerstone of adult preventive care, encompassing a thorough history, physical examination, counseling, and risk factor reduction interventions, along with the ordering of appropriate laboratory and diagnostic tests. The service is typically provided in an office setting and is designed to promote health maintenance and early detection of potential health issues.
Major national payers including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare recognize and reimburse for CPT 99386, underscoring its importance in preventive medicine. This publication provides a detailed overview of the code’s clinical context, payer coverage, and related policy considerations. Readers will gain insights into benchmarks for utilization, recent policy updates, and the role of this code in comprehensive adult preventive care. The analysis also highlights associated modifiers, relevant provider taxonomies, and common ICD-10 diagnoses used in conjunction with CPT 99386, offering a complete picture of its application in medical billing and practice management.
This summary serves as a resource for understanding the national landscape of preventive medicine billing for new adult patients, supporting informed decision-making in clinical and administrative settings.
CPT Code Overview
CPT 99386 is used for the initial comprehensive preventive medicine evaluation and management of a new patient aged 40 to 64 years. This service includes an age- and gender-appropriate history, examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of appropriate laboratory or diagnostic procedures. The typical site of service for this code is an office setting, designated as Place of Service 11. This code is central to preventive medicine, focusing on early detection and health maintenance for adults in the specified age range.
Clinical & Coding Specifications
Clinical Context
A 52-year-old new patient presents to a family medicine office for an initial comprehensive preventive medicine evaluation. The visit includes a detailed age- and gender-appropriate medical history, a thorough physical examination, counseling on lifestyle and risk factor reduction, and anticipatory guidance. The provider orders appropriate laboratory and diagnostic tests based on the patient's risk profile. The encounter is documented as a preventive service, and no acute complaints are addressed during the visit.
Coding Specifications
-
Modifier
25: Used when a significant, separately identifiable evaluation and management service is performed by the same physician on the same day as another procedure or service. -
Modifier
33: Indicates that the service provided is preventive in nature.
| Modifier Code | Description |
|---|---|
25 | Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day |
33 | Preventive Services |
- Provider Taxonomies:
| Taxonomy Code | Specialty |
|---|---|
207Q00000X | Family Medicine Physician |
208000000X | Pediatrics Physician |
207R00000X | Internal Medicine Physician |
Related Diagnoses
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Z00.00: Encounter for general adult medical examination without abnormal findings- Used when the preventive visit reveals no abnormal findings.
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Z00.01: Encounter for general adult medical examination with abnormal findings- Used when the preventive visit identifies abnormal findings.
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Z13.6: Encounter for screening for cardiovascular disorders- Relevant when cardiovascular screening is performed during the preventive visit.
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Z12.31: Encounter for screening mammogram for malignant neoplasm of breast- Used if a screening mammogram is ordered or performed as part of the preventive evaluation.
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Z13.89: Encounter for screening for other disorder- Used for other screenings conducted during the preventive visit that do not fall under more specific codes.
Related CPT Codes
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99385: Initial comprehensive preventive medicine evaluation and management for a new patient aged 18–39 years. Used for younger adults in a similar preventive context. -
99387: Initial comprehensive preventive medicine evaluation and management for a new patient aged 65 years and older. Used for older adults in a similar preventive context. -
99395: Periodic comprehensive preventive medicine re-evaluation and management for an established patient aged 18–39 years. Used for follow-up preventive visits in younger adults. -
99396: Periodic comprehensive preventive medicine re-evaluation and management for an established patient aged 40–64 years. Used for follow-up preventive visits in middle-aged adults.
These codes are alternatives based on patient age and whether the patient is new or established. They are not typically billed together in a single encounter but are used in similar preventive workflows.
National Reimbursement Benchmarks
For CPT code 99386, national mean rates among commercial payers are notably higher than typical Medicare rates, with UnitedHealth Group showing the highest mean rate at $207.44 and BUCA (average commercial) at $166.79. Commercial rates consistently exceed Medicare benchmarks, reflecting broader reimbursement trends.
Rate dispersion varies significantly across payers. Aetna has the tightest range between the 25th and 75th percentiles ($72.63), while Cigna and UnitedHealth Group exhibit the widest spreads ($117.50 and $114.33, respectively), indicating greater variability in negotiated rates. Blue Cross Blue Shield and BUCA display moderate dispersion.
The table and chart below present a detailed breakdown of national mean rates and percentile distributions for each payer.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.