Reviewed November 12, 2026
CPT 99396 is the periodic comprehensive preventive medicine visit for an established patient aged 40 to 64. CPT lets you report an office visit, 99212, 99213, 99214 or 99215, with modifier 25 when a problem needs significant additional work. Claims deny when the note cannot show that extra work, or when the payer is Medicare, which does not cover 99396.
The annual physical that turns into a blood-pressure medication change, a new knee complaint and a depression screen that needs follow-up is a familiar family-practice visit. The rule for billing both services is short. The denials come from not meeting it, and from applying a commercial rule to a Medicare patient.
What 99396 covers
Per AAPC Codify (code added 1992, descriptor last revised 1 January 2009) and the family wording the AMA prints in its 2023 modifier 25 guidance, 99396 is the periodic comprehensive preventive medicine reevaluation and management of an established patient aged 40 to 64, including an age- and gender-appropriate history, examination, counseling, anticipatory guidance and risk-factor reduction interventions, and the ordering of laboratory or diagnostic procedures. The same code family covers other age bands and new patients with their own codes; the rules below apply to all of them, and this post uses 99396 throughout.
Everything in that descriptor is the preventive service. Reviewing chronic conditions as part of the history, ordering routine labs, counseling on weight: none of it supports a second code on its own.
The CPT rule for a same-day problem visit
The AMA’s CPT Assistant guidance on modifier 25 (2023) states the preventive medicine instruction directly. If an abnormality is encountered or a pre-existing problem is addressed in the course of a preventive medicine service, and the problem is significant enough to require additional work to perform the key components of a problem-oriented E/M service, the appropriate office visit code is also reported. Three details from the same guidance decide most claims:
- Modifier 25 goes on the office visit code, 99212, 99213, 99214 or 99215. The preventive code is reported without a modifier.
- An insignificant or trivial problem that does not require significant additional work is not reported separately. The AMA’s Debunking Regulatory Myths page (updated 2 December 2025) puts it the same way: no extra E/M if the problem is trivial and does not need the key components of a problem-focused service.
- Different diagnoses are not required. CPT does not require a separate diagnosis for the E/M service, so a chronic condition managed at the physical can qualify if the work is there.
The E/M level is chosen the usual way, on medical decision making or total time, and the AMA’s key points say the E/M must meet its own criteria and be documented. The significance of the problem and the time and decision making it required are what support the level, not the fact that the patient also had a physical.
Medicare is different: 99396 is not covered
CMS’s Medicare Wellness Visits page (last modified 8 April 2026) is explicit: a routine physical exam performed without relationship to treatment or diagnosis of a specific illness is not covered, and the patient pays 100% out of pocket. What Medicare covers instead is the Initial Preventive Physical Exam, G0402, within 12 months of Part B enrollment, and the Annual Wellness Visit, G0438 for the first and G0439 for each subsequent visit, once every 12 months and not within 12 months of G0402 (CMS Annual Wellness Visit page, last modified 9 April 2026).
MLN Matters MM13548 (released 14 March 2024, effective 15 May 2024) updated the Medicare Claims Processing Manual, Chapter 12, to say it plainly: do not bill AWV services with the comprehensive preventive medicine codes, which include 99396 (§30.6.1.1). Section 30.6.2 adds that a written Advance Beneficiary Notice is not required for the routine physical portion of a visit, but CMS strongly encourages one, and the physician is responsible for telling the patient in advance that they will owe for it.
For the problem portion, CMS’s Annual Wellness Visit page says Medicare may pay a significant, separately identifiable, medically necessary E/M service with the AWV: report 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214 or 99215 with modifier 25, and that portion must be medically necessary to treat the patient’s illness or injury. So the Medicare version of this visit is G0438 or G0439 plus an office visit with modifier 25. If the patient wants a routine physical instead, §30.6.2 treats a covered problem visit on the same occasion as provided in lieu of part of the non-covered physical: Medicare pays the visit, and the patient may be charged only the amount by which the practice’s charge for the physical exceeds its charge for the visit.
Why the claim denies
The problem was not significant. A note that lists “hypertension, stable, continue lisinopril” inside the physical’s review of systems does not describe the key components of a separate E/M service. The AMA’s test is additional work. If the note cannot show it, the payer will not either.
Modifier 25 is on the wrong code. CPT Assistant places it on the office visit. A 99396-25 with an unmodified 99213 is the reverse of the instruction.
99396 went to Medicare. Per the Claims Processing Manual and the CMS wellness pages, it is non-covered, and the patient is liable for the physical beyond any covered visit. If the patient was eligible for G0438 or G0439 and received the AWV elements, the AWV was the billable service.
The commercial plan’s policy differs. The AMA’s Debunking Regulatory Myths page notes that commercial payers, depending on the patient’s specific policy, may or may not cover the additional problem-focused E/M at the same visit as the preventive service. Pull the policy for your largest plans rather than treating one denial as the rule. The same page warns that billing both codes can change the patient’s out-of-pocket cost, and suggests physicians may discuss that at the time of service.
Documentation that supports both codes
- A separate problem section in the note: the history relevant to the problem, the examination findings beyond the routine physical, and the assessment and plan, as the AMA’s 3-year-old otitis media example lays out.
- An E/M level supported on its own by medical decision making or total time, per CPT Assistant’s key points.
- The preventive elements intact, so 99396 stands on its own descriptor.
- For Medicare patients, the AWV elements, with the problem visit documented as medically necessary, and an ABN if the patient also wants a non-covered physical (not required, but CMS strongly encourages one).
- A front-desk script for the cost-sharing conversation the AMA suggests.
For the Medicare side in depth, see AWV vs. annual physical coding. For the wider preventive code set, see preventive services billing for family practice, and our resources library for the family practice CPT cheat sheet.
If your preventive-plus-problem claims pay the physical and drop the visit, AMS Solutions, billing for practices since 1992, works these edits as part of our family practice billing services.
