Initial preventive medicine, age 40-64 years, new patient
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Patient classification error - new vs. established
Common99393 is for established patient preventive, late childhood (5-11 years). Denied when patient should be coded as new patient (99383 - hasn't been seen in 3+ years). The 3-year rule applies: if patient hasn't been seen by any physician of same specialty in same group practice in past 3 years, they're 'new' for billing purposes. Common when child changes doctors within same practice.
Common Causes
- • Child hasn't been seen in 3+ years - should use new patient code 99383
- • Child switched to different doctor within same practice (still considered established)
- • Previous visits were with different specialty in same practice (may be new)
Resolution Strategy
Verify last visit date by same specialty provider. If within 3 years, appeal as established. If 3+ years, accept new patient code (99383). If different specialty saw child, may qualify as new.
Relative Value Units (RVUs)
Calculator →
Clinical Information
When to Use
Comprehensive preventive medicine evaluation for new patients age 40-64
Common Scenarios
Documentation Requirements
- Comprehensive age and gender-appropriate history including detailed family history
- Complete physical examination with attention to age-appropriate findings
- Comprehensive cancer screening discussion and orders
- Cardiovascular risk assessment and stratification
- Baseline laboratory and imaging studies coordination
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
- Highest RVU preventive code due to age range and new patient status
Exclusions
- 99201-99215 (problem-based office visits without modifier 25)
- 99383-99387 (established patient preventive codes)
- 99392, 99394 (different age ranges)
Coding Notes
Clinical scenarios
- Comprehensive age and gender-appropriate history including detailed family history
- Complete physical examination with attention to age-appropriate findings
- Comprehensive cancer screening discussion and orders
- Comprehensive age and gender-appropriate history including detailed family history
- Complete physical examination with attention to age-appropriate findings
- Comprehensive cancer screening discussion and orders
- Comprehensive age and gender-appropriate history including detailed family history
- Complete physical examination with attention to age-appropriate findings
- Comprehensive cancer screening discussion and orders
Who are you?
Code Details
Medicare Pricing
PFSRVU Breakdown
OPPS Details
Automate Coding
Let OrbDoc AI automatically suggest codes from your clinical notes.
Patient? Check your bill.
Use our free analyzer to understand charges and spot errors.
Analyze My BillAsk OrbDoc AI
Get instant answers about 99393 - pricing, bundling rules, or billing questions.
Ask a QuestionRelated Solutions & Resources
Primary Care Solutions
Optimize documentation for office visits and improve workflow efficiency
Primary Care Setup Guide
Complete guide for configuring AI medical scribe in primary care practices
Medicare Billing Optimization
Capture AWV, TCM, CCM, RPM revenue with accurate documentation
Surgical Documentation
Accurate procedure documentation for surgical centers
Frequently Asked Questions
CPT 99393 is the billing code for "Initial preventive medicine, age 40-64 years, new patient". Comprehensive preventive medicine evaluation for new patients age 40-64
Medicare pays approximately $101.24 for CPT 99393 (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 99393 has a total RVU of 5.08, broken down as: Work RVU 2.82, Practice Expense RVU 2.08, and Malpractice RVU 0.18. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99393 is "Patient classification error - new vs. established". 99393 is for established patient preventive, late childhood (5-11 years). Denied when patient should be coded as new patient (99383 - hasn't been seen in 3+ years). The 3-year rule applies: if patient hasn't been seen by any physician of same specialty in same group practice in past 3 years, they're 'new' for billing purposes. Common when child changes doctors within same practice. Common causes include: Child hasn't been seen in 3+ years - should use new patient code 99383; Child switched to different doctor within same practice (still considered established). Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 99393 include: Comprehensive age and gender-appropriate history including detailed family history; Complete physical examination with attention to age-appropriate findings; Comprehensive cancer screening discussion and orders; Cardiovascular risk assessment and stratification. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99393: 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 99393 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 99393 is Typically 50-60 minutes for comprehensive new patient preventive visit. Time-based codes require documentation of the actual time spent providing the service.