CPT Code 99385: Initial Preventive Visit, New Patient, 18-39 Years

CPT code 99385 reports an initial comprehensive preventive medicine evaluation for a new patient aged 18 through 39. 

It belongs to the preventive medicine E/M category — not standard office E/M — and carries no MDM level, no time threshold, and no component-counting requirement. 

Code selection depends on whether the encounter is a genuinely preventive, age-appropriate well visit for a new patient in the specified age bracket.

The most important billing reality about 99385 is that Medicare does not separately pay for it. 

Medicare covers its own preventive benefit through the Initial Preventive Physical Examination (G0402) and Annual Wellness Visit (G0438/G0439) — not through CPT preventive codes. Billing 99385 to Medicare typically results in denial. 

However, 99385 remains widely used with commercial payers and Medicaid programs, where initial preventive visits are covered benefits. 

The commercial median reimbursement sits around ~$194 — making correct 99385 usage a meaningful revenue line for practices with younger patient panels.

What does CPT code 99385 cover?

The essential reference facts for 99385 billing.

Detail	CPT 99385
Description	Initial comprehensive preventive visit, new patient, 18-39 years
Category	Preventive Medicine E/M
Patient type	New only
MDM level	N/A (not standard E/M)
Time	No CPT-defined threshold
Age range	18-39 years
Common modifiers	25, 33
Medicare coverage	Not separately payable (use G0402/G0438/G0439)
Commercial rate (median)	~$194
Commonly compared with	CPT 99395

99385 covers the “annual physical” or “wellness exam” for a new patient in the 18-39 age range. The encounter should include age-appropriate history, examination, counseling, risk-factor assessment, and anticipatory guidance — the preventive medicine scope, not a problem-oriented visit.

When should you use CPT 99385?

99385 applies when a genuinely preventive encounter occurs for a new patient within the 18-39 age range.

Use CPT 99385 when

• The payer is commercial or Medicaid (not Medicare)
• The patient is aged 18 through 39 at the date of service
• The patient is new (CPT three-year/same-specialty rule)
• The encounter is a comprehensive preventive evaluation — not a problem-oriented visit
• Age-appropriate history, examination, counseling, and risk-factor assessment are performed

When not to use it

• The patient is established — use 99395 for established preventive visits in the same age range
• The payer is Medicare — bill G0402, G0438, or G0439 instead
• The visit is problem-focused rather than preventive — bill the appropriate office E/M code (99202-99205)
• The patient is outside the 18-39 age bracket — use the corresponding age-range preventive code (99384, 99386, etc.)
• A significant problem is addressed during the preventive visit — bill the problem-oriented E/M separately with modifier 25

How is CPT 99385 selected?

99385 has no MDM pathway and no time threshold. Selection depends on the nature of the encounter (preventive vs. problem-oriented), the patient status (new), and the age range (18-39).

Preventive scope

The encounter must be comprehensive and preventive in nature — age-appropriate screening, counseling, and risk-factor assessment. 

CPT does not specify a minimum examination scope for preventive codes the way pre-2021 E/M did for office visit codes.

Same-day problem management

When a significant, separately identifiable problem is addressed during the same encounter, the appropriate office E/M code (99202-99205) can be reported alongside 99385 with modifier 25 on the problem-oriented E/M. 

The preventive visit and the problem-oriented visit must be documented independently.

What documentation supports CPT 99385?

The note should reflect a genuinely preventive encounter — not a problem-oriented visit repackaged as a physical.

Documentation should include: 

• Immunization status review
• Comprehensive examination
• Counseling and anticipatory guidance
• Age-appropriate history (personal, family, social)
• Risk-factor assessment and screening recommendations

When a same-day problem is addressed alongside the preventive visit, document the problem-oriented work in a separate section so the E/M-25 is clearly independently supported.

How much does CPT 99385 reimburse?

99385 is not a Medicare-payable service. Payment applies to commercial and Medicaid plans.

Payment type	2026 rate
Medicare	Not separately payable
Commercial payers (median)	~$194
Medicaid	Varies by state

Commercial median from FAIR Health national cost estimate data (2026).

Commercial reimbursement varies significantly by plan. 

ACA-compliant plans must cover preventive services without cost-sharing under the ACA preventive-care mandate, which means 99385 should be covered at $0 patient cost when billed with appropriate preventive diagnosis codes (Z00.00/Z00.01). 

However, the provider reimbursement amount still depends on the negotiated contract rate.

Which modifiers apply to CPT 99385?

Modifier	When it applies
25	On the separately reported problem-oriented E/M when a significant problem is addressed same day
33	Preventive services — appended to the preventive code to flag ACA-mandated $0 cost-sharing
95	Telehealth (limited — most preventive visits include physical examination)

Modifier 25 goes on the problem-oriented E/M code — not on 99385 itself. When billing both, 99385 is the preventive encounter and the 992XX code-25 captures the separately identifiable problem work.

CPT 99385 vs. 99395 — which one fits?

The only difference is patient status — new versus established.

Feature	CPT 99385	CPT 99395
Patient type	New	Established
Age range	18-39	18-39
Service	Comprehensive preventive visit	Periodic preventive visit
Medicare	Not payable	Not payable
Commercial rate (median)	~$194	~$184

Choose 99385 when the patient is new under the three-year/same-specialty rule and the visit is preventive.

Choose 99395 when the patient is established, and the visit is a periodic preventive follow-up.

The ~$10 commercial rate difference reflects the slightly higher work involved in the initial encounter. 

Do not bill 99385 for an established patient simply because the rate is marginally higher — patient status is verified against the CPT three-year rule, and payers can detect the mismatch.

What billing errors should you avoid with CPT 99385?

Five errors drive the majority of 99385 denials.

1. Billing 99385 to Medicare 

Medicare does not separately pay for CPT preventive visit codes. Use G0402 (IPPE), G0438 (initial AWV), or G0439 (subsequent AWV) for Medicare beneficiaries.

2. Wrong age range 

99385 covers ages 18-39. A 17-year-old needs 99384; a 40-year-old needs 99386. Verify the patient’s age at the date of service.

3. Billing a problem-oriented visit as preventive 

An encounter driven by a specific complaint (chest pain, rash, joint pain) is a problem-oriented visit — not a preventive exam. Bill the appropriate 992XX office E/M, not 99385.

4. Missing modifier 25 on same-day problem E/M 

When addressing a significant problem during the preventive visit, the problem-oriented E/M needs modifier 25 to indicate separately identifiable work. Missing it triggers denial on the E/M claim.

5. Using established-patient code for a new patient 

99395 is for established patients. 99385 is for new patients. Mixing them up based on scheduling status rather than CPT’s three-year/same-specialty rule creates a coding error.

Frequently asked questions about CPT 99385

Here are some commonly asked questions about this topic: