Initial preventive medicine, age 65 years and older, new patient
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Not covered as preventive - problem-focused visit miscoded
Common99394 (established adolescent preventive 12-17 years) should only be used for true preventive health maintenance visits. When visit primarily addresses acute illness or chronic disease management, it's problem-focused and should use regular E&M codes (99212-99215). Denials occur when medical problem was primary purpose of visit but coded as preventive. Diagnosis codes also matter: preventive codes (Z00.x) vs. problem codes.
Common Causes
- • Visit primarily for sports physical with problem addressed - should be problem E&M
- • Visit for medication refill or disease management coded as preventive
- • Diagnosis codes indicate medical problem, not preventive screening
Resolution Strategy
If visit truly preventive, appeal with documentation of age-appropriate screening, counseling, anticipatory guidance. If primarily for medical problem, recode as problem-focused E&M (99212-99215) with appropriate diagnosis codes. Cannot turn problem visit into preventive visit after the fact.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Comprehensive preventive medicine evaluation for new patients age 65 and older
Common Scenarios
Documentation Requirements
- Comprehensive geriatric history including detailed functional status
- Complete physical examination with geriatric focus
- Cognitive screening and assessment
- Fall risk evaluation and home safety assessment
- Comprehensive medication review and reconciliation
- Advance care planning initiation
Coding Guidelines
Common Modifiers
Bundling Rules
- Cannot be billed for Medicare patients (use G0402 for initial Medicare preventive visit)
- Can be billed with problem-based E/M using modifier 25
- For non-Medicare patients age 65+ only
Exclusions
- G0402 (Initial Preventive Physical Examination for Medicare)
- G0438-G0439 (Medicare Annual Wellness Visit)
- 99201-99215 (problem-based office visits without modifier 25)
- 99384-99387 (established patient preventive codes)
Coding Notes
Clinical scenarios
- Comprehensive geriatric history including detailed functional status
- Complete physical examination with geriatric focus
- Cognitive screening and assessment
- Comprehensive geriatric history including detailed functional status
- Complete physical examination with geriatric focus
- Cognitive screening and assessment
- Comprehensive geriatric history including detailed functional status
- Complete physical examination with geriatric focus
- Cognitive screening and assessment
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Code Details
Medicare Pricing
PFSRVU Breakdown
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Frequently Asked Questions
CPT 99394 is the billing code for "Initial preventive medicine, age 65 years and older, new patient". Comprehensive preventive medicine evaluation for new patients age 65 and older
Medicare pays approximately $110.63 for CPT 99394 (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 99394 has a total RVU of 5.37, broken down as: Work RVU 2.98, Practice Expense RVU 2.20, and Malpractice RVU 0.19. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99394 is "Not covered as preventive - problem-focused visit miscoded". 99394 (established adolescent preventive 12-17 years) should only be used for true preventive health maintenance visits. When visit primarily addresses acute illness or chronic disease management, it's problem-focused and should use regular E&M codes (99212-99215). Denials occur when medical problem was primary purpose of visit but coded as preventive. Diagnosis codes also matter: preventive codes (Z00.x) vs. problem codes. Common causes include: Visit primarily for sports physical with problem addressed - should be problem E&M; Visit for medication refill or disease management coded as preventive. Appeal success rate is approximately 10-30%.
Key documentation requirements for CPT 99394 include: Comprehensive geriatric history including detailed functional status; Complete physical examination with geriatric focus; Cognitive screening and assessment; Fall risk evaluation and home safety assessment. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99394: Cannot be billed for Medicare patients (use G0402 for initial Medicare preventive visit). 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 99394 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 99394 is Typically 60-70 minutes for comprehensive new geriatric patient. Time-based codes require documentation of the actual time spent providing the service.