Initial comprehensive preventive medicine, age 18-39
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Same-day problem-oriented E/M without proper documentation
Very CommonBilling both preventive visit (99385) and problem-oriented E/M (99213-99215) on same day requires Modifier 25 on the E/M and clear documentation of significant, separately identifiable problem.
Common Causes
- • Minor issue addressed during preventive visit billed separately
- • Missing Modifier 25 on problem-oriented E/M code
- • Documentation doesn't distinguish preventive work from problem work
Resolution Strategy
Document significant, separately identifiable problem clearly distinct from preventive visit. Ensure Modifier 25 on E/M code. Commercial payers often pay 50% of E/M, which is policy, not error.
2. Age doesn't match code range
Occasional99385 is for ages 18-39. Using this code for patients outside this age range triggers automatic denial.
Common Causes
- • Patient turned 40 but visit coded with 99385 instead of 99386
- • Patient is 17 and adolescent code should be used
- • Clerical error selecting wrong age-based code
Resolution Strategy
Correct the age-appropriate code and resubmit. Simple administrative correction.
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Frequently Asked Questions
CPT 99385 is the billing code for "Initial comprehensive preventive medicine, age 18-39". It falls under the Evaluation & Management category and is used by healthcare providers to bill insurance for this specific service.
Medicare pays approximately $126.15 for CPT 99385 (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.
The most common denial reason for CPT 99385 is "Same-day problem-oriented E/M without proper documentation". Billing both preventive visit (99385) and problem-oriented E/M (99213-99215) on same day requires Modifier 25 on the E/M and clear documentation of significant, separately identifiable problem. Common causes include: Minor issue addressed during preventive visit billed separately; Missing Modifier 25 on problem-oriented E/M code. Appeal success rate is approximately 40-60%.