Initial preventive medicine, age 18-39 years, new patient
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Same-day E&M without Modifier 25
Very CommonWhen preventive visit (99392 - established early childhood 1-4 years) occurs same day as problem-focused sick visit, both can be billed if significant and separately identifiable. However, Modifier 25 must be appended to problem-focused E&M code to indicate separate service. Without Modifier 25, payer denies problem visit as bundled into preventive visit. This is the #1 preventive visit denial when well-child and sick-child visits combined.
Common Causes
- • Same-day well-child and sick-child visit without Modifier 25 on problem E&M
- • Documentation doesn't clearly separate preventive service from problem evaluation
- • Problem addressed during preventive visit but billed as separate E&M
Resolution Strategy
Provider adds Modifier 25 to problem E&M code (not preventive code) and documents clearly separate services: preventive screening/immunizations vs. evaluation of specific medical problem (e.g., ear infection, rash). Most payers accept appeals with proper modifier and separation documentation.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Comprehensive preventive medicine evaluation for new patients age 18-39
Common Scenarios
Documentation Requirements
- Comprehensive age and gender-appropriate history
- Complete physical examination
- Family history and genetic risk assessment
- Comprehensive preventive screening and counseling
- Establishment of baseline health parameters
Coding Guidelines
Common Modifiers
Bundling Rules
- Cannot be billed with established patient preventive codes
- Can be billed with problem-based E/M using modifier 25
- New patient: not seen within past 3 years by physician in same specialty
Exclusions
- 99201-99215 (problem-based office visits without modifier 25)
- 99382-99387 (established patient preventive codes)
- 99381-99391 (different age ranges)
Coding Notes
Clinical scenarios
- Comprehensive age and gender-appropriate history
- Complete physical examination
- Family history and genetic risk assessment
- Comprehensive age and gender-appropriate history
- Complete physical examination
- Family history and genetic risk assessment
- Comprehensive age and gender-appropriate history
- Complete physical examination
- Family history and genetic risk assessment
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PFSRVU Breakdown
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Frequently Asked Questions
CPT 99392 is the billing code for "Initial preventive medicine, age 18-39 years, new patient". Comprehensive preventive medicine evaluation for new patients age 18-39
Medicare pays approximately $101.24 for CPT 99392 (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 99392 has a total RVU of 4.50, broken down as: Work RVU 2.50, Practice Expense RVU 1.84, and Malpractice RVU 0.16. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99392 is "Same-day E&M without Modifier 25". When preventive visit (99392 - established early childhood 1-4 years) occurs same day as problem-focused sick visit, both can be billed if significant and separately identifiable. However, Modifier 25 must be appended to problem-focused E&M code to indicate separate service. Without Modifier 25, payer denies problem visit as bundled into preventive visit. This is the #1 preventive visit denial when well-child and sick-child visits combined. Common causes include: Same-day well-child and sick-child visit without Modifier 25 on problem E&M; Documentation doesn't clearly separate preventive service from problem evaluation. Appeal success rate is approximately 70-80%.
Key documentation requirements for CPT 99392 include: Comprehensive age and gender-appropriate history; Complete physical examination; Family history and genetic risk assessment; Comprehensive preventive screening and counseling. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99392: Cannot be billed with established 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 99392 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 99392 is Typically 40-50 minutes for comprehensive new patient preventive visit. Time-based codes require documentation of the actual time spent providing the service.