CPT code 99386 reports an initial comprehensive preventive medicine evaluation for a new patient aged 40 through 64. It belongs to the preventive medicine E/M category and carries no MDM, 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.
Medicare does not separately pay for 99386 — use the Initial Preventive Physical Examination (G0402) or Annual Wellness Visit (G0438/G0439) for Medicare beneficiaries.
Commercial payers widely cover 99386, and the ACA preventive-care mandate requires $0 patient cost-sharing when billed with Z00.00/Z00.01 diagnosis codes.
The commercial median sits around ~$220 — the highest among new-patient preventive codes for this age bracket, reflecting the documentation burden of a first-time intake.
What does CPT code 99386 cover?
An initial preventive visit for a new patient aged 40-64 involves substantially more work than a periodic visit for an established patient.
The physician collects a full personal, family, and social history from scratch, performs a complete examination, and establishes baseline risk assessments for cardiovascular disease, diabetes, and age-appropriate cancers.
The ~$220 commercial rate reflects that documentation burden.
| Detail | CPT 99386 |
| Description | Initial comprehensive preventive visit, new patient, 40-64 years |
| Category | Preventive Medicine E/M |
| Patient type | New only |
| Age range | 40-64 years |
| Medicare coverage | Not separately payable |
| Commercial rate (median) | ~$220 |
| Commonly compared with | CPT 99396 |
CPT Code Snapshot
99386 — New Patient Preventive (40-64)
Patient Type
New
Age Range
40-64
Commercial Median
~$220
Accurate preventive coding from the first visit
MedHeave prevents new-patient preventive coding errors and makes sure same-day E/M add-ons capture the full revenue your documentation supports.
When should you use CPT 99386?
Three conditions must be true simultaneously for 99386 to be the correct code — the patient must be new, aged 40-64, and the encounter must be genuinely preventive.
Missing any one of those three sends the claim to a different code family entirely.
Use CPT 99386 when
- The payer is commercial or Medicaid (not Medicare)
- The patient is new under CPT’s three-year/same-specialty rule
- The encounter is an initial comprehensive preventive evaluation
- The patient is aged 40 through 64 at the date of service
A 48-year-old patient presents to a new primary care practice for an initial wellness evaluation.
The physician collects a full personal, family, and social history, performs a complete physical examination, orders baseline lipid and metabolic panels, discusses colorectal cancer screening options, and reviews immunization status.
No specific complaint is addressed. The visit is billed as 99386 with diagnosis Z00.00.
When not to use it
Some encounters look like a new-patient preventive visit but belong under a different code because the patient status, payer, or encounter purpose does not match 99386’s requirements.
- Established patient → use 99396
- Medicare → bill G0402/G0438/G0439
- Problem-focused visit → bill 99204/99205
- Wrong age bracket → use 99385 (18-39) or 99387 (65+)
How is CPT 99386 selected?
Unlike standard E/M codes, 99386 has no MDM grid, no time threshold, and no element-counting requirement. Selection rests entirely on three encounter-level facts — encounter type (preventive), patient status (new), and patient age (40-64).
The “new patient” determination follows CPT’s three-year/same-specialty rule.
A patient who has not received any face-to-face professional service from any physician in the same group practice with the same specialty within the prior three years qualifies as new. A patient seen three years ago by a different specialty within the same group does not automatically qualify — the specialty must match.
When a new or existing problem surfaces during the preventive visit and the physician addresses it beyond what the preventive exam normally covers, the problem-oriented work supports a separate new-patient E/M (99202-99205) with modifier 25.
Both the preventive note and the problem-oriented note need independent documentation.
Encounter Decision
New patient wellness + problem same day?
Preventive Only
99386
Preventive + Problem
99386 + E/M-25
Problem Only
99204/99205
What documentation supports CPT 99386?
An initial preventive visit for a new 40-64 patient requires more thorough documentation than a periodic visit because the physician is building the patient’s baseline record from scratch.
Required documentation elements include:
- Metabolic screening discussion.
- Complete head-to-toe physical examination.
- Comprehensive personal, family, and social history.
- Immunization review and administration, if indicated.
- Mental health screening documentation, when performed.
- Behavioral counseling on tobacco, alcohol, diet, and physical activity.
- Cardiovascular risk assessment (blood pressure, lipid screening, and BMI).
- Cancer screening recommendations appropriate for the 40–64 population (colorectal beginning at 45, breast, cervical, and lung for qualifying smokers).
When a problem is addressed during the same visit, the problem-oriented documentation must stand on its own — separate chief complaint, separate assessment, separate plan.
A single blended note risks a denial on both the preventive and the E/M claim.
How much does CPT 99386 reimburse?
Commercial reimbursement for 99386 runs higher than its established-patient counterpart (99396) because the initial visit carries a greater documentation burden and clinical workload. Medicare does not pay for any CPT preventive code in this family.
| Payment type | 2026 rate |
| Medicare | Not separately payable |
| Commercial payers (median) | ~$220 |
| Medicaid | Varies by state |
Commercial median from FAIR Health national cost estimate data (2026). ACA-compliant plans cover at $0 patient cost-sharing with Z00.00/Z00.01.
The ~$21 difference between 99386 (~$220) and 99396 (~$199) reflects the additional history-gathering and baseline-establishment work on a new patient.
Practices that miss the same-day E/M add-on when a problem is addressed alongside the preventive visit leave additional revenue on the table — the problem E/M reimburses separately.
Which modifiers apply to CPT 99386?
Preventive codes use fewer modifiers than standard E/M, but the two that apply to 99386 carry significant claim-accuracy implications.
| Modifier | When it applies |
| 25 | Appended to the separately reported problem E/M when a significant, separately identifiable problem is addressed on the same day as the preventive visit |
| 33 | Appended to 99386 itself to flag the service as ACA-preventive, triggering $0 patient cost-sharing on ACA-compliant plans |
Modifier 25 is the most audit-sensitive modifier on same-day preventive claims.
The OIG modifier-25 audit found widespread overuse, so the documentation supporting the problem E/M must clearly establish a separate chief complaint, separate history, and a distinct plan beyond the preventive exam.
CPT 99386 vs. 99396 — which one fits?
Patient status is the sole difference between these two codes. Both cover the same age range, the same clinical scope, and the same screening obligations. Picking the wrong one triggers a denial for incorrect patient classification.
| Feature | CPT 99386 | CPT 99396 |
| Patient type | New | Established |
| Age range | 40-64 | 40-64 |
| Commercial rate (median) | ~$220 | ~$199 |
| Medicare | Not payable | Not payable |
| Encounter type | Initial wellness | Periodic wellness |
Choose 99386 when the patient has not been seen by any provider of the same specialty in the same group within the prior three years and presents for an initial preventive evaluation.
Choose 99396 when the patient is established (seen within the past three years) and returns for a periodic preventive visit.
Code Comparison
99386 vs. 99396
99386 — New
Initial wellness, age 40–64
~$220
99396 — Established
Periodic wellness, age 40–64
~$199
What billing errors should you avoid with CPT 99386?
New-patient preventive claims carry specific error patterns beyond those seen on established-patient visits. The new-patient determination itself is a frequent audit target, and the higher reimbursement rate (~$220 vs. ~$199 for 99396) draws closer payer scrutiny.
1. Billing 99386 to Medicare
Medicare does not recognize CPT preventive codes. Submitting 99386 to a Medicare plan results in an automatic denial, not a reduced payment or crosswalk to G0402.
The correct Medicare codes for new beneficiaries are G0402 (IPPE within the first 12 months of Part B) or G0438 (initial Annual Wellness Visit).
Practices that serve both Medicare and commercial patients need payer-specific encounter workflows — commercial patients get 99386 — Medicare patients get routed to the G-code pathway at scheduling.
2. Established patient coded as new
The three-year/same-specialty rule determines new-patient status.
A patient seen 30 months ago by the same specialty within the same group is established, not new — billing 99386 instead of 99396 inflates the claim by ~$21 and creates audit exposure.
Registration staff should verify new-patient status against the practice management system before the encounter, not rely on the patient’s self-report. Payers cross-reference claims history to catch misclassifications.
3. Wrong age bracket at date of service
99386 covers patients aged 40 through 64. A patient who is 39 at the date of service falls under 99385, and a patient who has turned 65 belongs under 99387.
Age verification happens at scheduling and again at check-in — relying on birth year alone without confirming the exact date of birth against the service date produces avoidable rejections.
4. Missing modifier 25 on the same-day problem E/M
When a physician addresses a significant problem during the preventive visit, the problem-oriented E/M (99202-99205 for new patients) requires modifier 25 to indicate a separately identifiable service.
Without modifier 25, the payer bundles the problem E/M into the preventive visit and pays only the 99386 rate. The lost revenue on the E/M is entirely recoverable with proper modifier assignment and independent documentation.
5. Using a problem-oriented diagnosis as the primary ICD-10
99386 requires a preventive diagnosis code as the primary ICD-10 — typically Z00.00 (encounter for general adult medical examination without abnormal findings) or Z00.01 (with abnormal findings).
Listing a problem-oriented diagnosis (hypertension, diabetes, back pain) as the primary code signals to the payer that the visit was not preventive, triggering a denial or reclassification. Problem diagnoses belong on the separately billed E/M line, not on the 99386 line.
Frequently asked questions about CPT 99386
Here are some commonly asked questions on this topic:
CPT 99386 reports an initial comprehensive preventive medicine visit for a new patient aged 40 through 64. The visit covers complete personal, family, and social history intake from scratch, a full physical examination, cardiovascular and metabolic risk assessment, cancer screening recommendations (colorectal beginning at 45, breast, cervical, lung where indicated), immunization review, and behavioral counseling on tobacco, alcohol, and physical activity. It applies to commercial and Medicaid payers only — Medicare does not pay for CPT preventive codes and uses G0402 or G0438 instead.
Medicare does not pay for CPT preventive medicine codes, including 99386. New Medicare beneficiaries have access to the IPPE (G0402, “Welcome to Medicare” visit) within their first 12 months of Part B enrollment, after which the Annual Wellness Visit (G0438 for initial, G0439 for subsequent) becomes the preventive benefit. Submitting 99386 to a Medicare plan produces an automatic denial that cannot be rebilled without a corrected claim submission. Practices must route Medicare patients to the G-code pathway at scheduling, not at claim submission, to prevent this denial entirely.
Yes, when a separately identifiable problem is addressed during the preventive visit. The physician must document the problem-oriented work independently — separate chief complaint, separate history of present illness, separate assessment and plan. The problem E/M (99202-99205 for new patients) carries modifier 25 to indicate a distinct service beyond the preventive exam. Both the preventive visit and the problem visit are payable when the documentation supports each as a standalone encounter. Without independent documentation, the payer bundles the E/M into the preventive payment and the practice absorbs the lost revenue.
Patient status is the sole difference. CPT 99386 is for new patients (not seen within the past three years by the same specialty in the same group), while 99396 is for established patients returning for a periodic preventive visit. Both codes cover the same age range (40-64), the same clinical scope, and the same screening expectations. The commercial rate difference is approximately 21(~220 for 99386 vs. ~$199 for 99396), reflecting the greater documentation burden on initial evaluations.
