99396 CPT Code: Reimbursement Rates and Insurance Rules

In primary care and adult wellness visits billing, CPT code 99396 is extremely important for preventive medicine. It concerns billing for adult preventive medicine visits for adult patients aged 40-64, who are established patients. Although they occur frequently in practice, rules regarding reimbursement and coverage for these visits are highly payer and practice specific. A large majority of claim denials occur because of the fact that these visits are governed by a different set of billing rules than service oriented visits. The identification of billing within CPT 99396 and determination of which payers reimbursement this code and matching documentation requirements is important for billing within the bounds of the payer contract and being correctly reimbursed for the services. The purpose of this blog is to provide insights on CPT code 99396 to minimize errors in billing and maximize revenue for the practice and billing department.

What Is CPT Code 99396?

As an example, let’s take CPT 99396. This is described as a periodic comprehensive preventive medicine reevaluation and management service for established patients between the ages of 40 and 64. This encompasses age and gender appropriate history, and physical exam, counseling, and anticipatory guidance, risk factor reduction and ordering of appropriate labs/diagnostics. Most commonly, this is the CPT code used for annual physical exams, or wellness visits when the focus is on prevention of disease, and not the management of any acute or chronic conditions. Since this service is primarily preventive, it is quite different from the traditional evaluation and management codes that are used for illness-related visits.

Age is also important; different codes in preventive medicine apply to patients younger than or older than 40–64. CPT 99396 also does not cover detailed evaluation or management of pre-existing medical conditions. If important medical problems are resolved during the same visit, different coding implications apply. Using this code appropriately means understanding the preventive focus of this code and following the strict documentation rules.

Reimbursement Rates: What to Expect

The reimbursement rates for CPT code 99396 differ based on the payer, geographical area, and the provider’s contractual agreements. Generally, preventive medicine services are reimbursed by commercial insurance due to the focus on preventive care in these employer-sponsored and Affordable Care Act-compliant health plans. For CPT 99396, private insurers, on average, reimburse between $150 and $250 for each visit, but depending on the practice and the market, negotiated reimbursement rates could be higher.
Medicare regulations state that private insurance companies including Blue Cross Blue Shield, Aetna, Cigna, and UnitedHealthcare are allowed to create their own fee schedules that can vary within the same insurance company and are dependent on plan type, employer group size, and network arrangements. Because there are so many variables, practices are encouraged to review their payer contracts so that they can identify the exact reimbursement amount per contract for CPT 99396. If they want to maximize the reimbursement for CPT 99396, practices must verify benefits and submit claims timely.

Medicare (Traditional)

Original Medicare Part B fails to reimburse CPT code 99396. Medicare has stated that comprehensive preventative visits marked by CPT codes 99381 to 99397 are not covered. Instead, Medicare coverage goes to Annual Wellness Visits that employ particular HCPCS G-codes. CPT 99396 is submitted to Medicare; the claim is denied as a service that is not covered, no matter what the medical documentation supports, or what the medical necessity is.
For Medicare beneficiaries, providers need to use G0438 for the first Annual Wellness Visit and G0439 for the follow-up visits. These services are different in structure and documentation than CPT 99396, and they emphasize on health risk assessments and preventive strategies rather than a head-to-toe physical exam. This is very important so that billing and patient anger do not get out of hand from denials.

Medicare Advantage & Private Medicare Plans

Medicare Advantage plans have the option for extra benefits and cover some services differently than Original Medicare. Some Medicare Advantage plans even cover fees associated with CPT code 99396 as a preventative service in addition to the Annual Wellness Visit. However, coverage for this service is not guaranteed and is very inconsistent among plans, with some even having different coverages for the same service within the same insurance company. Some plans cover this service as a preventative care visit, while others do not cover it at all.
Because there is such inconsistency for coverage for preventative services, it is extremely important to double check the policies of Medicare Advantage plans to ensure there is coverage. Unconfirmed coverage for this service could potentially lead to claim denials or costly bills being sent to the patient. It is crucial to clearly inform your patient of any potential costs associated with preventative services before billing under Medicare Advantage plans.

Medicare Advantage & Private Medicare Plans

Medicaid coverage for CPT code 99396 differs by each state, as well as each managed care organization. Some state Medicaid programs do reimburse some services under preventative medicine, although it is usually at a reduced rate. Others may do something completely different, like change the service code, or even do something really unique, like impose certain age restrictions. In states where Medicaid does reimburse for CPT 99396, it is usually much lower than what commercial insurance would cover, typically within the range of $70-120 per visit.
Prevention visits may be restricted and extra documentation may be required by a managed Medicaid plan. Providers must analyze managed care contracts and Medicaid in their individual state. Due to the frequency with which Medicaid policies change, staying current with billing regulations is the best way to keep reimbursements steady.

Insurance Rules & Billing Policies

Insurance companies are very rigorous when it comes to billing for the services associated with the code 99396. The most critical of these is the service-provision distinction between preventive care and problem-oriented care. This code is exclusive to preventive care and cannot be used when the visit’s primary objective is to assess and manage a particular problem. If there are major medical problems that arise on the occasion of a preventive visit, providers may bill for an additional evaluation and management (E/M) code, but only if the service is considered to be distinct and separately documented.
Insurers also impose visit frequency caps on their members, and preventive care visits are no exception. Some insurers state that code 99396 can only be billed once every calendar year, and others stipulate that an entire 365-day period must pass before billing can occur again. If you submit your claims too soon, there is a high chance that you may be denied. Every time there is a check for preventive care and with each individual insurer, there is a control that insurance companies do to lessen the number of claims that get denied.

Medicare Rules: Special Considerations

Medicare Services Guidelines involve a broad variety of services and include specific rules that providers and billing departments need to pay special attention to. G-codes must be used for wellness visits as traditional Medicare enrollees do not qualify for coverage of CPT 99396. CPT 99396 should not be submitted to Medicare as this will result in repetitive denials and disappointment in dollar losses to billing staff salaries. Scheduling and educating patients correctly, Medicare patients will receive services that are preventative, and to which they are entitled. The guidelines will state that coverage for Medicare Advantage patients are based entirely on the benefit structure of that individual plan. Some of these plans do cover CPT 99396, while others follow only Medicare Guidelines with G-codes. These situations require good documentation and billing practices.

Common Errors That Lead to Denials

Reducing billing denials on CPT 99396 starts with good documentation and billing practices. The number one billing error is that the code is billed on patients who do not qualify due to not meeting age requirements or not being established patients. Another issue is that the code is being billed to traditional Medicare, which is against the guidelines. This is a covered service for Medicare patients which is why it is having to code it, but this is where not understanding the guidelines on the use of modifier 25 in these situations, and it will only trigger denials, or leave the claims open to audit due to the lack of a documented service that is unrelated.
Claims can be rejected for missing or incorrectly coded diagnoses. Documents for an insurance claim linked to a preventive visit should include an ICD-10 Z-code. If an insurer does not receive one of these Z-codes, they may think the visit was an ordinary office visit and refuse to pay the claim.

Documentation Requirements

When billing CPT 99396, documentation must be precise and complete. The records should reflect a full preventive examination, including an adequate history, physical exam, and counselling. The focus of the documentation should be on the maintenance of health, risk factor evaluation, preventive education screenings, and education and should avoid disease control. If there are any abnormal findings, mention should be made of them, but the focus of the visit should not be on the findings, but rather on the preventive aspects.
If any other evaluation and management services are rendered, the documentation should be clear in differentiating the preventive from the problem-oriented components. This clarification helps to warrant the appropriate use of modifiers and better supports the rationale for reimbursement of multiple services provided on the same date.

Best Practices for Billing and Revenue Management

The first step in CPT 99396 reimbursement is completion of benefit verification which, if done correctly, leads to successful CPT 99396 reimbursement. Verifying coverage, whether patients have hit frequency limits, and understanding payer-specific policies will lead to fewer denials and increased patient satisfaction. Adding Z-codes, especially Z-codes from the range of ICD-10 Z-codes, along with detailed documentation will fortify claims and reduce the chances of an audit. Providers need to keep track of changes in payer policies related to preventive services, since those are continually changing.
Having billing and coding employee training performed regularly is essential in ensuring that all employees have an understanding of the preventive service(s) offered and the nuances of each respective payer. In addition, having solid revenue cycle management policies put into practice will allow a practice to seize every preventive care service offered, while also adhering to the guidelines outlined by care plan insurance.