A unique medical specialty recognized by the American Board of Medical Specialties (ABMS), preventive medicine services or well visits aim at protecting, promoting, and maintaining health and well-being and preventing disease, disability, and death for individuals, communities, and defined populations. Medicare explains that the goals of these wellness visits are health promotion and disease prevention and detection. Preventive medicine has three specialty areas – aerospace medicine, occupational medicine, and public health and general preventive medicine. Medical coding services to document preventive visits involve using the correct CPT and ICD-10 codes to report the services provided.

Services provided will also vary by patient circumstance. While the services for a young child will assess physical growth and developmental milestones such as speech, crawling, and sleeping habits, an adolescent preventive service may include scoliosis screening, assessment of growth and development, and a review of immunizations. A comprehensive preventive visit for an adult female patient will include a gynecologic examination, pap smear, and breast exam and for an adult male’s exam, services would include an examination of the scrotum, testes, penis, and the prostate for older patients.

The preventive comprehensive exam is different from a problem-oriented comprehensive exam, as its components are based on age and risk factors rather than a presenting problem. Unlike other evaluation and management (E/M) services, preventive services do not have specific documentation guidelines required to support the service provided.

CPT codes

CPT defines a preventive medicine service as an age – and gender-appropriate comprehensive history and physical exam that includes anticipatory guidance and risk factor reduction. A dedicated set of CPT codes to describe preventive medicine services range from 99381 to 99397. These codes can report the preventive evaluation and management (E/M) of infants, children, adolescents, and adults.
Code assignment is determined by the patient’s age (as detailed in the code descriptor), and whether the patient is new (99381-99387) or established (99391-99397).

New Patient

  • 99381 Initial comprehensive preventive medicine evaluation 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, new patient; infant (age younger than 1 year)
  • 99382 ———; early childhood (age 1 through 4 years)
  • 99383 ———; late childhood (age 5 through 11 years)
  • 99384 ———; adolescent (age 12 through 17 years)
  • 99385 ———; 18-39 years
  • 99386 ———; 40-64 years
  • 99387 ———; 65 years and older

Established Patient

  • 99391 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; infant (age younger than 1 year)
  • 99392 ———; early childhood (age 1 through 4 years)
  • 99393 ———; late childhood (age 5 through 11 years)
  • 99394 ———; adolescent (age 12 through 17 years)
  • 99395 ———; 18-39 years
  • 99396 ———; 40-64 years
  • 99397 ———; 65 years and older

It is recommended to report the appropriate Office/Outpatient code from 99201-99215, if an abnormality is encountered in the process of performing this preventive medicine evaluation and management service, and if additional work is significant to perform the key components of a problem-oriented E/M service. Modifier 25 should also be added to the office/outpatient code to indicate that a significant, separately identifiable E/M service was provided on the same day as the preventive medicine service.

ICD-10 Codes

Every billed service must be supported by an ICD-10-CM code(s) that describe the reason for that service.

  • Z00.110 Health examination for newborn under 8 days old
  • Z00.111 Health examination for newborn 8 to 28 days old
  • Z00.121 Encounter for routine child health examination with abnormal findings
  • Z00.129 Encounter for routine child health examination without abnormal findings
  • Z00.00 Encounter for general adult medical examination without abnormal findings
  • Z00.01 Encounter for general adult medical examination with abnormal findings
  • Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
  • Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Even though the Affordable Care Act (ACA) requires insurers to cover recommended preventive services without any patient cost-sharing, exact coverage and reporting requirements may vary from payer to payer. Experienced medical billing and coding companies provide the services of skilled medical coders who are up to date with the coding changes and updates related to E/M and preventive medicine services.