CPT Code 99395: Periodic Preventive Visit, Established Patient (18-39 Years)

CPT code 99395 reports a periodic comprehensive preventive medicine evaluation for an established patient aged 18 through 39. It belongs to the preventive medicine E/M category 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 an established patient in the specified age bracket.

Like its new-patient counterpart 99385, Medicare does not separately pay for 99395. Medicare covers preventive care through the Annual Wellness Visit (G0438/G0439) rather than CPT preventive codes. 

Commercial payers, however, widely cover 99395 — and the ACA preventive-care mandate requires ACA-compliant plans to cover it at $0 patient cost-sharing when billed with appropriate preventive diagnosis codes. The commercial median reimbursement sits around ~$184.

What does CPT code 99395 cover?

The essential reference facts for 99395 billing.

Detail	CPT 99395
Description	Periodic comprehensive preventive visit, established patient, 18-39 years
Category	Preventive Medicine E/M
Patient type	Established only
MDM level	N/A (not standard E/M)
Time	No CPT-defined threshold
Age range	18-39 years
Common modifiers	25 (on same-day E/M), 33
Medicare coverage	Not separately payable (use G0438/G0439)
Commercial rate (median)	~$184
Commonly compared with	CPT 99385

99395 covers the periodic “annual physical” for an established patient — the routine wellness check-up. The scope is preventive, not problem-oriented.

When should you use CPT 99395?

99395 applies when a genuinely preventive encounter occurs for an established patient within the 18-39 age range.

Use CPT 99395 when

• The patient is established (seen within the past three years)
• The patient is aged 18 through 39 at the date of service
• The encounter is a periodic preventive evaluation — not problem-oriented
• The payer is commercial or Medicaid (not Medicare)

When not to use it

• The patient is new — use 99385
• The payer is Medicare — bill G0438 or G0439 instead
• The visit is problem-focused — bill the appropriate established-patient E/M (99211-99215)
• The patient is outside the 18-39 age bracket — use the corresponding age-range code (99394, 99396, etc.)

How is CPT 99395 selected?

No MDM pathway, no time threshold. Selection depends on the nature of the encounter (preventive), the patient status (established), and the age range (18-39).

Same-day problem management

When a significant problem is addressed during the preventive visit, bill the appropriate established-patient E/M (99211-99215) with modifier 25 alongside 99395. Document the preventive and problem-oriented components independently.

The most common same-day scenario — a patient comes for their annual physical and mentions persistent knee pain. T

he preventive exam is 99395. The knee evaluation, if it involves separate history, examination, and MDM, is 99213-25 (or whatever level the clinical work supports). Both claims need independent documentation.

What documentation supports CPT 99395?

The note should reflect a preventive encounter — age-appropriate history review, examination, counseling, risk-factor assessment, screening recommendations, and immunization status. When a same-day problem is addressed, document the problem-oriented work separately.

How much does CPT 99395 reimburse?

Payment type	2026 rate
Medicare	Not separately payable
Commercial payers (median)	~$184
Medicaid	Varies by state

Commercial median from FAIR Health national cost estimate data (2026). ACA-compliant plans must cover at $0 patient cost-sharing with preventive diagnosis codes.

Which modifiers apply to CPT 99395?

Modifier	When it applies
25	On the separately reported problem E/M when a significant problem is addressed same day
33	Preventive services — flags ACA-mandated $0 cost-sharing

Modifier 25 goes on the E/M code, not on 99395.

CPT 99395 vs. 99385 — which one fits?

The only difference is patient status.

Feature	CPT 99395	CPT 99385
Patient type	Established	New
Age range	18-39	18-39
Service	Periodic preventive	Initial preventive
Commercial rate (median)	~$184	~$194

Choose 99395 for an established patient’s periodic wellness visit.

Choose 99385 for a new patient’s initial wellness visit.

What billing errors should you avoid with CPT 99395?

Four errors drive the majority of 99395 denials.

1. Billing 99395 to Medicare 

Medicare uses G0438/G0439, not CPT preventive codes. Billing 99395 to Medicare results in denial.

2. Wrong age range 

99395 covers ages 18-39. Verify the patient’s age at the date of service against the CPT age brackets.

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

When a significant problem is addressed alongside the preventive visit, the problem-oriented E/M needs modifier 25. Omitting it triggers denial on the E/M claim.

4. Billing a problem-oriented visit as preventive 

An encounter driven by a specific complaint is problem-oriented. Bill the appropriate office E/M, not 99395.

Frequently asked questions about CPT 99395

Here are some commonly asked questions on this topic: