CPT 99395: preventive medicine visit, established patient, ages 18 to 39
99395 reports a periodic preventive medicine visit for an established patient aged 18 through 39. It is a wellness visit, not a problem visit, and its billing turns on the payer: Medicare lists it as a non-covered service, while commercial plans must usually cover preventive care without cost-sharing under federal rules.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · Last reviewed October 2026In short: 99395 is the preventive visit for an established patient aged 18 to 39. Medicare does not cover routine physicals and flags the whole 99381 to 99397 family as non-covered, so Medicare patients get the annual wellness visit (G0438 or G0439) instead. A separate problem visit on the same day is where most denials start.
What does CPT 99395 report?
99395 is a preventive medicine E/M code: a periodic comprehensive check-up for an established patient aged 18 through 39. CMS labels it "Prev visit est age 18-39". Its neighbours step by age: 99396 for 40 to 64 and 99397 for 65 and over, with 99385 as the new-patient code for 18 to 39.
| Item | Value in the file |
|---|---|
| Payment status | N (non-covered service) |
| Work RVU shown in the file | 1.75, informational only |
| Global period | XXX |
| MUE value and indicator | 0, with indicator 3 (date of service edit, rationale "CMS Policy") |
The fee schedule file defines status N as a service not covered by Medicare, and says only RVUs on status A, R and T codes are used for Medicare payment.
Does Medicare pay for CPT 99395?
No. 42 CFR 411.15(a)(1) excludes routine physical checkups, meaning examinations for a purpose other than treating or diagnosing a specific illness, symptom, complaint or injury. The same rule lists exceptions, including the initial preventive physical examination and annual wellness visits. Chapter 12 section 30.6.2 of the Claims Processing Manual calls 99381 to 99397 a noncovered service.
Chapter 12 also tells practices what to bill instead. The first annual wellness visit is billed with G0438 and later ones with G0439, and the manual adds "Do not bill for AWV services using CPT codes 99381-99397."
| Code | CMS label | Status | Work RVU |
|---|---|---|---|
| G0438 | Ppps, initial visit | A | 2.60 |
| G0439 | Ppps, subseq visit | A | 1.92 |
| 99395 | Prev visit est age 18-39 | N | 1.75 (informational) |
Under 42 CFR 410.15 the AWV is for a beneficiary who is past 12 months from the start of Part B and has had no initial preventive physical examination or AWV in the past 12 months. Chapter 12 says the G0438 is once per beneficiary per lifetime.
Can a preventive visit and a problem visit be billed together?
Under Medicare, section 30.6.2 handles it by treating the covered problem visit as taking the place of part of the noncovered preventive service. The practice may bill the patient the amount by which its preventive charge exceeds its charge for the covered visit, and CMS strongly encourages an ABN even though one is not required for the routine portion. See ABN.
With commercial plans the answer is in the plan's rules, but one federal rule shapes the patient's bill. 45 CFR 147.130(a)(2) lets a plan charge cost-sharing for an office visit when the preventive item is billed separately from it, and bars cost-sharing when the item is not billed separately and the visit's primary purpose is the preventive service. The problem visit should be separate, supported and carry modifier 25 where the payer requires it.
How does 99395 appear on the claim?
On the CMS-1500, 99395 goes in Item 24D with 1 unit in Item 24G and the place of service in Item 24B. The NCCI practitioner MUE table effective October 1, 2026 lists 99395 at 0 with adjudication indicator 3 and the rationale "CMS Policy", which fits the status N entry: Medicare does not pay the code.
A problem visit billed alongside it is 99213 or 99214, leveled by MDM or time on its own. From 2025, G2211 can still be paid with a modifier 25 office visit on the same day as an AWV, vaccine administration or Part B preventive service.
How does a 99395 preventive visit look on the form?
The preventive visit takes one line in Item 24D, and the diagnosis pointer in Item 24E usually goes to a wellness encounter code listed first in Item 21. Chapter 26 gives each service line one reference letter, so when a problem is also addressed, the separate E/M line takes its own pointer to the problem diagnosis rather than sharing the wellness one.
RVU26D marks 99395 status N and the MUE table lists 0 units with the rationale CMS Policy, so a Medicare claim for it is not expected to pay. Commercial plans and Medicaid set their own age and interval rules, which is why eligibility checks come before the visit.
Example: A 29-year-old commercial patient has a yearly exam on 10/09 and also mentions knee pain. Item 21 reads A Z00.00 and B M25.561. Line 1 is 99395, pointer A, 1 unit, $210.00. Line 2 is 99213 with modifier 25, pointer B, 1 unit, $98.00. If both lines pointed to A, the payer could deny the second as part of the first under CO-97.
Why is 99395 denied?
| Code | What X12 says | What usually causes it |
|---|---|---|
| CO-96 | Non-covered charge(s) | Medicare billed for a preventive visit it excludes |
| PR-96 | Non-covered charge(s), under group code PR (patient responsibility) | The plan excludes the exam and passes it to the patient |
| CO-119 | Benefit maximum for this time period or occurrence has been reached | A second preventive visit in the benefit year |
| CO-4 | The procedure code is inconsistent with the modifier used | Modifier 25 on the wrong visit or a missing modifier on the problem visit |
If these denials keep coming back, our denial management team can work them. Related reading: family medicine billing, 99392 for ages 1 to 4, chronic care management 99490 and medical coding.
Related codes
- Physician Fee Schedule relative value files, RVU26D (October 2026) · CMS
- Medicare NCCI Medically Unlikely Edits, practitioner services table, effective 10-01-2026 · CMS
- Medicare Claims Processing Manual, Chapter 12: Physicians/Nonphysician Practitioners · CMS
- Evaluation and Management Services (MLN006764, May 2026) · CMS
- 42 CFR 411.15: Particular services excluded from coverage · eCFR
- 42 CFR 410.15: Annual wellness visits providing Personalized Prevention Plan Services · eCFR
- 45 CFR 147.130: Coverage of preventive health services · eCFR
- CY 2025 Physician Fee Schedule final rule (89 FR 97710) · Federal Register
- Claim Adjustment Reason Codes · X12
- Medicare Claims Processing Manual, Chapter 26: Completing and Processing Form CMS-1500 Data Set · CMS
We check every rule, code and deadline against the official source. See our editorial policy.
Common questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01Can a preventive visit and a problem visit be billed together?
Yes, as two separate services when the problem visit is significant and separately identifiable. Medicare treats a covered problem visit as replacing part of a noncovered preventive visit. Commercial plans follow their own policy, and 45 CFR 147.130 decides whether the patient owes cost-sharing on the visit portion.
02Does Medicare cover CPT 99395?
No. The fee schedule lists 99395 as status N, non-covered, and 42 CFR 411.15 excludes routine physical checkups. Medicare covers the annual wellness visit, billed with G0438 for the first and G0439 for later ones, and never with 99381 to 99397.
03What age does 99395 cover?
CMS labels 99395 as the established-patient preventive visit for ages 18 to 39. Ages 40 to 64 use 99396 and 65 and over use 99397. New patients in the 18 to 39 band use 99385. Choose by the patient's age on the date of service.
04Should I use 99395 or G0439 for a Medicare patient?
Use G0438 or G0439 for an eligible Medicare patient's wellness visit. Chapter 12 states not to bill AWV services with 99381 to 99397. The patient must be past 12 months from Part B start and have had no AWV or initial preventive exam in the last 12 months.
05What is the NCCI MUE for 99395?
The practitioner MUE table effective October 1, 2026 lists 99395 at 0 units with adjudication indicator 3 and the rationale CMS Policy. That matches its status N on the fee schedule, where Medicare does not cover the service, so a Medicare claim for it will not pass the edit.
06Can G2211 be paid on a day with a preventive visit?
For Medicare, G2211 can be paid with an office visit carrying modifier 25 when an AWV, vaccine administration or Part B preventive service is also done that day, per the CY 2025 final rule. It still needs a qualifying relationship, and Medicare does not pay 99395 itself.
Wellness visits denied or paid as sick visits?
We check payer preventive rules and the problem visit coding before the claim is sent.