99395

Preventive Medicine Evaluation and Management, Established Patient, 18-39 Years

CPT 99395 is used for the periodic comprehensive preventive medicine reevaluation and management of an established patient between the ages of 18 and 39 years. This encounter is fundamentally different from a problem-oriented visit as its primary objective is the promotion of health, the identification of risk factors, and the early detection of asymptomatic diseases. An established patient is defined as one who has received professional services from the physician or another physician of the same specialty and subspecialty in the same group practice within the previous three years. The service includes an age and gender-appropriate history, which involves an update of the patient's medical, surgical, family, and social history, as well as a review of systems. A comprehensive physical examination is performed, which generally includes the measurement of vital signs, height, weight, and body mass index (BMI), along with a thorough assessment of various organ systems including the cardiovascular, respiratory, and musculoskeletal systems. The physician provides counseling, anticipatory guidance, and risk factor reduction interventions tailored to the young adult population, addressing concerns such as diet and exercise, substance use, sexual health, and mental health screenings. Additionally, the service involves the ordering or review of appropriate laboratory and diagnostic procedures, such as screening for cervical cancer in females or lipid profiles based on risk. If a significant, separately identifiable medical problem is addressed during the same visit, a separate evaluation and management code may be reported with modifier 25, provided the documentation supports the additional work.

Clinical Indications

  • Routine annual physical examination for healthy adults aged 18-39
  • Screening for chronic diseases such as hypertension and obesity
  • Preventive counseling for lifestyle modifications including diet and physical activity
  • Assessment and update of immunization status
  • Reproductive health counseling and screening
  • Mental health and behavioral health screenings (e.g., depression or substance abuse screening)
  • Identification and management of risk factors for cardiovascular disease

Procedure Steps

  1. Verify the patient's status as an established patient (seen within the last 3 years).
  2. Obtain and document an interval medical, surgical, family, and social history.
  3. Conduct a comprehensive review of systems to identify any new or asymptomatic concerns.
  4. Perform a physical examination including vitals (BP, heart rate), height, weight, and BMI calculation.
  5. Execute a multisystem physical exam (head, neck, heart, lungs, abdomen, skin, and extremities).
  6. Perform age and gender-specific screenings (e.g., pelvic exam/Pap smear for females, if indicated).
  7. Provide counseling and anticipatory guidance regarding nutrition, exercise, and safety.
  8. Screen for tobacco, alcohol, and drug use, and provide cessation or reduction advice.
  9. Review and update the patient's vaccination record (e.g., Tdap, Flu, HPV).
  10. Order appropriate screening laboratory tests (e.g., STIs, lipids, glucose) based on risk factors.
  11. Document all findings and the plan for follow-up or further diagnostic testing.

Coding Guidelines

  • Code 99395 is for established patients only; use 99385 for new patients in the 18-39 age group.
  • Preventive medicine codes are based on the age of the patient, not the complexity of a specific disease.
  • Immunizations and the administration of vaccines are reported separately and are not bundled into 99395.
  • If a separate medical problem is addressed that requires significant additional work, use a sick-visit E/M code (e.g., 99212-99215) with modifier 25.
  • Screening laboratory tests, such as a Pap smear lab or a lipid panel, should be billed separately.
  • Do not report 99395 in conjunction with a work or school physical (use 99450 or specific E/M codes) if the service is not comprehensive.
  • Counseling for risk factor reduction is included in 99395 unless it is a separate, extensive session (see 99401-99412).

Associated ICD-10 Codes