Summary & Overview
CPT 99396: Periodic Preventive Visit for Established Adults 40–64
CPT 99396 represents a comprehensive periodic preventive medicine reevaluation for established adults aged 40–64 years. This preventive visit combines a focused history, physical examination, counseling and anticipatory guidance, risk‑factor reduction interventions, and ordering of appropriate laboratory or diagnostic tests. As a nationally recognized preventive service, it supports population health efforts by facilitating screening, early detection, and counseling aimed at reducing chronic disease risk.
Key payers in scope include Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare. Readers will find a concise account of coverage considerations and billing structure relevant to these major commercial payers, including common modifier usage and associated diagnostic contexts. The publication provides clinical context for how this preventive visit fits into routine adult care, comparisons to adjacent age-group preventive codes, and practical coding boundaries to distinguish preventive services from problem-oriented evaluation and management services.
The analysis is intended to inform billing, coding, and payer-coverage awareness for clinicians and administrative staff. Sections include benchmarks for service setting and utilization patterns where available, documentation expectations tied to comprehensive preventive visits, and guidance on commonly adjacent CPT codes to clarify age-based code selection. Data not available in the input is noted where applicable.
CPT Code Overview
CPT 99396 is a periodic comprehensive preventive medicine reevaluation and management visit for an established adult patient aged 40–64 years. The service includes an age- and gender‑appropriate history, physical examination, counseling/anticipatory guidance, risk‑factor reduction interventions, and the ordering of laboratory or diagnostic procedures as appropriate.
Service Type: Preventive Medicine Services
Typical Site of Service: Office (POS 11)
Clinical & Coding Specifications
Clinical Context
A 52-year-old established patient presents to their primary care office (POS 11) for a routine periodic preventive medicine visit. The visit includes an age- and gender-appropriate history, a comprehensive physical examination, counseling and anticipatory guidance on risk factor reduction (such as cardiovascular risk, cancer screening, lifestyle modification), and ordering of appropriate laboratory or screening tests. Typical workflow: patient checks in and completes preventive health questionnaire; medical assistant documents vitals, updates medication list and immunizations; clinician performs focused preventive history and comprehensive exam, provides counseling, orders screening tests (for example, lipid panel, mammogram if indicated), and documents the visit as a periodic comprehensive preventive medicine reevaluation using 99396 when the patient is an established individual aged 40–64 years.
Coding Specifications
-
Modifier
25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service- Use when a distinct E/M service beyond the preventive visit is provided and documented on the same date as another procedure or service. Documentation must support a separately identifiable evaluation and management service.
-
Modifier
33: Preventive Services- Use to indicate a preventive service when required by payer policy. Applies when the service is reported as preventive rather than problem-focused.
-
Associated provider taxonomies:
| Taxonomy Code | Specialty |
|---|---|
207R00000X | Family Medicine |
207RR0500X | Internal Medicine |
Related Diagnoses
-
Z00.00- Encounter for general adult medical examination without abnormal findings- This diagnosis documents a routine preventive exam with no abnormal findings, appropriate for reporting a preventive medicine visit coded with
99396.
- This diagnosis documents a routine preventive exam with no abnormal findings, appropriate for reporting a preventive medicine visit coded with
-
Z00.01- Encounter for general adult medical examination with abnormal findings- This diagnosis is used when the preventive exam identifies abnormal findings that are addressed during the visit; it may accompany
99396when findings are documented.
- This diagnosis is used when the preventive exam identifies abnormal findings that are addressed during the visit; it may accompany
-
Z13.6- Encounter for screening for cardiovascular disorders- Applicable when the preventive visit includes screening for cardiovascular risk factors (for example, blood pressure assessment, lipid screening) ordered or performed as part of
99396.
- Applicable when the preventive visit includes screening for cardiovascular risk factors (for example, blood pressure assessment, lipid screening) ordered or performed as part of
-
Z12.31- Encounter for screening mammogram for malignant neoplasm of breast- Applies when breast cancer screening is part of the preventive services ordered or coordinated during the
99396visit for age- and gender-appropriate patients.
- Applies when breast cancer screening is part of the preventive services ordered or coordinated during the
-
Z12.4- Encounter for screening for malignant neoplasm of cervix- Applies when cervical cancer screening (for example, Pap test or HPV testing) is performed or ordered as part of the preventive medicine encounter coded with
99396.
- Applies when cervical cancer screening (for example, Pap test or HPV testing) is performed or ordered as part of the preventive medicine encounter coded with
Related CPT Codes
| CPT Code | Description |
|---|---|
99394 | Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) |
99395 | Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18‑39 years |
99397 | Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older |
-
Relationship to
99396: -
99394,99395, and99397are age-specific sibling codes covering the same periodic comprehensive preventive medicine service for different patient age ranges. They serve as alternatives based on patient age. -
In clinical workflow, the clinician selects
99396when the patient is an established adult aged 40–64 years; the other codes are used for established patients in their respective age brackets. -
These codes are mutually exclusive for the same visit; only the single age-appropriate periodic preventive medicine code is reported for the preventive service.
National Reimbursement Benchmarks
National commercial mean rates for 99396 are notably higher than Medicare-level reimbursement; BUCA (the combined commercial benchmark) has a mean of $138.66 versus Medicare at $0.00 in the provided input, indicating Medicare values are not present in the dataset. Across commercial payers, UnitedHealth Group posts the highest mean at $174.13 while Aetna and Blue Cross Blue Shield sit lower at $130.64 and $136.74 respectively.
Dispersion (P75 minus P25) varies across payers: UnitedHealth Group shows one of the widest spreads (212.75 − 115.50 = $97.25), and Cigna also displays a wide range (194.50 − 98.50 = $96.00). BCBS and BUCA have moderate dispersion (BCBS: $54.00; BUCA: $65.08), while Aetna is relatively tighter (155 − 93 = $62.00). The table and chart below present the full numeric breakdown 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.