Initial preventive medicine, age 40-64 years, established patient
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Age doesn't match code range - late childhood 5-11 years
Very Common99383 is for new patient preventive visits, late childhood (ages 5-11 years). Denied when patient is under 5 years (use 99382) or 12+ years (use 99384 for adolescent). Common at age 11-12 boundary when child turns 12 before visit date.
Common Causes
- • Child under 5 years - should be 99382
- • Child 12 years or older - should be 99384
- • Visit scheduled at age 11 but occurred after 12th birthday
Resolution Strategy
Verify child's age at visit date. If 5-11 years, appeal with proof. If outside range, correct to appropriate code (99382 or 99384) and resubmit.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Comprehensive preventive medicine evaluation for established patients age 40-64
Common Scenarios
Documentation Requirements
- Comprehensive age and gender-appropriate history including family history
- Complete physical examination
- Age-appropriate cancer and disease screening
- Cardiovascular risk stratification
- Lifestyle and preventive counseling
Coding Guidelines
Common Modifiers
Bundling Rules
- Cannot be billed with new patient preventive codes
- Can be billed with problem-based E/M using modifier 25
- Includes all preventive counseling and screening coordination
Exclusions
- 99201-99215 (problem-based office visits without modifier 25)
- 99393-99397 (new patient preventive codes)
- G0438-G0439 (Medicare Annual Wellness Visit)
Coding Notes
Clinical scenarios
- Comprehensive age and gender-appropriate history including family history
- Complete physical examination
- Age-appropriate cancer and disease screening
- Comprehensive age and gender-appropriate history including family history
- Complete physical examination
- Age-appropriate cancer and disease screening
- Comprehensive age and gender-appropriate history including family history
- Complete physical examination
- Age-appropriate cancer and disease screening
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Frequently Asked Questions
CPT 99383 is the billing code for "Initial preventive medicine, age 40-64 years, established patient". Comprehensive preventive medicine evaluation for established patients age 40-64
Medicare pays approximately $115.48 for CPT 99383 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99383 has a total RVU of 4.03, broken down as: Work RVU 2.24, Practice Expense RVU 1.65, and Malpractice RVU 0.14. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99383 is "Age doesn't match code range - late childhood 5-11 years". 99383 is for new patient preventive visits, late childhood (ages 5-11 years). Denied when patient is under 5 years (use 99382) or 12+ years (use 99384 for adolescent). Common at age 11-12 boundary when child turns 12 before visit date. Common causes include: Child under 5 years - should be 99382; Child 12 years or older - should be 99384. Appeal success rate is approximately 70-80%.
Key documentation requirements for CPT 99383 include: Comprehensive age and gender-appropriate history including family history; Complete physical examination; Age-appropriate cancer and disease screening; Cardiovascular risk stratification. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99383: Cannot be billed with new patient preventive codes. Can be billed with problem-based E/M using modifier 25 Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99383 include: 25 (Significant, separately identifiable E/M for problem-based visit on same day), 33 (Preventive services (payer-specific)). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 99383 is Typically 40-50 minutes for comprehensive preventive visit. Time-based codes require documentation of the actual time spent providing the service.