9938X

Initial Comprehensive Preventive Medicine Evaluation and Management, New Patient (Age 18-39)

A comprehensive preventive medicine evaluation and management (E/M) service for a new patient aged 18-39 years. This service includes an age- and gender-appropriate history, physical examination, counseling, anticipatory guidance, and risk factor reduction interventions, performed in the absence of a significant presenting illness, symptom, or established chronic condition requiring problem-oriented E/M services at the same encounter. The goal is to promote health and prevent disease.

Clinical Indications

  • Routine annual health check-up for a new patient.
  • Health risk assessment and identification of potential health issues.
  • Screening for common asymptomatic conditions (e.g., hypertension, hyperlipidemia, diabetes).
  • Counseling on healthy lifestyle choices (diet, exercise, smoking cessation, alcohol use).
  • Immunization status review and administration recommendations.
  • Early detection of diseases through appropriate screenings based on age and risk factors.

Procedure Steps

  1. Obtain a comprehensive medical and family history, including social history, past medical history, surgical history, and medication review.
  2. Perform a comprehensive physical examination, appropriate for age and gender.
  3. Assess health risk factors (e.g., lifestyle, genetic predispositions, environmental exposures).
  4. Provide age-appropriate health education and anticipatory guidance (e.g., safety, nutrition, physical activity, sexual health).
  5. Discuss and recommend appropriate immunizations and screenings (e.g., pap smear, mammogram, colonoscopy, STI screening, cholesterol screening).
  6. Counsel on risk reduction strategies (e.g., smoking cessation, alcohol moderation, stress management).
  7. Order appropriate laboratory or diagnostic tests as indicated by age, risk factors, or screening guidelines.
  8. Document findings, recommendations, and patient plan in the medical record.

Coding Guidelines

  • Code 99385 is used for *new* patients only. For established patients, use the 9939X series (e.g., 99395).
  • This code should be used when the primary purpose of the visit is a preventive examination, not for evaluation of a significant new or existing illness.
  • If a significant problem is addressed during the preventive visit, and it requires additional work beyond the typical preventive service, a separate problem-oriented E/M code (e.g., 9920x or 9921x) may be billed with modifier 25 appended to the E/M code, in addition to the preventive code.
  • The age range for 99385 is 18-39 years. Select the appropriate code from the 99381-99387 series based on the patient's age.
  • Counseling and anticipatory guidance must be a significant component of the service to qualify as a comprehensive preventive medicine E/M.

Associated ICD-10 Codes