CPT Code Overview

CPT 99385 describes an initial comprehensive preventive medicine evaluation and management visit for a new patient aged 18–39 years. The service includes an age- and gender-appropriate history, physical examination, counseling and anticipatory guidance, risk-factor reduction interventions, and ordering of appropriate laboratory or diagnostic procedures. This code is used for preventive care encounters focused on health promotion and disease prevention rather than problem-focused evaluation.

Service type: Preventive medicine evaluation and management

Typical site of service: Office (e.g., physician office setting)

Clinical Context

A 28-year-old new patient presents to a primary care office for a routine preventive visit. The patient schedules an initial comprehensive preventive medicine evaluation with a Family Medicine physician in an outpatient office setting. The visit includes an age- and gender-appropriate comprehensive history, a complete physical examination, counseling and anticipatory guidance (including risk factor reduction and lifestyle counseling), and ordering of screening laboratory and diagnostic tests as appropriate. The visit is documented as a new patient preventive encounter and may result in a diagnosis of Z00.00 (no abnormal findings) or Z00.01 (with abnormal findings) depending on findings. If a routine gynecological exam is performed with or without abnormal findings, Z01.411 or Z01.419 may be recorded. The clinical workflow typically includes pre-visit intake (forms, medication list), in-person evaluation by the physician, documentation of preventive counseling and ordered screening tests, and placement of orders for labs or imaging in the electronic health record. Billing uses the preventive medicine initial comprehensive E/M code 99385 for a new patient aged 18–39 years in the office.

Coding Specifications

• 25 — Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service: Use when a distinct E/M service (beyond the preventive visit content) is documented and meets E/M requirements on the same calendar day as another procedure or visit. Documentation must support the separate, significant evaluation and management.

• 33 — Preventive service: Use to indicate that the service is a preventive care service as defined by payors. This modifier is applied when the visit is billed as a preventive service to facilitate appropriate payer processing.

Associated provider taxonomies:

Notes on taxonomies:

• 207Q00000X represents Family Medicine physicians who commonly provide comprehensive preventive care across the adult age spectrum.

• 208000000X represents Pediatrics physicians; included where preventive services overlap late-adolescent to young-adult care within the 18–39 age range.

• 207R00000X represents Internal Medicine physicians who provide adult preventive care for the specified age group.

Related Diagnoses

• Z00.00 — General adult medical examination without abnormal findings

  This code documents a routine preventive medical exam in which no abnormal findings are identified during the comprehensive evaluation; it is appropriate when 99385 is billed and the exam is normal.

• Z00.01 — General adult medical examination with abnormal findings

  This code is used when abnormal findings are identified during the preventive visit that warrant documentation; it may accompany 99385 when the preventive exam reveals clinical issues.

• Z01.411 — Encounter for gynecological examination (general) (routine) with abnormal findings

  This code applies when a routine gynecologic component performed during the preventive visit yields abnormal findings; it may be recorded in addition to the preventive visit code as clinically appropriate.

• Z01.419 — Encounter for gynecological examination (general) (routine) without abnormal findings

  This code applies when a routine gynecologic component is performed during the preventive visit and no abnormal findings are found; it may accompany 99385 to specify the gynecologic exam result.

Related CPT Codes

• 99386 and 99387 are age-based initial preventive medicine codes for older new patients and serve as direct age-tier alternatives to 99385 when the patient falls into the 40–64 or 65+ age ranges.

• 99395 is the established patient periodic preventive visit equivalent for the 18–39 year age group and is used for follow-up periodic exams rather than an initial new patient visit; it is commonly used in longitudinal preventive care following an initial 99385.

• These codes are alternatives based on patient status (new versus established) and patient age; they may be used in sequence across a patient’s care timeline (e.g., initial 99385 followed by periodic 99395).

The national mean for Medicare is not provided in the input, while BUCA (the composite commercial benchmark) reports a mean allowed rate of $143.08 for CPT 99385, slightly above Aetna and BCBS and below UnitedHealth Group and Cigna. BUCA's mean is within the mid-range of commercial payers in the dataset.

Dispersion measured as the difference between the 75th and 25th percentiles varies across payers. UnitedHealth Group shows one of the widest spreads (214.00 - 118.00 = $96.00), indicating greater variability. Cigna also shows wide dispersion (200.50 - 99.50 = $101.00). Aetna and BCBS are tighter by comparison (Aetna: 159.00 - 95.50 = $63.50; BCBS: 163.00 - 109.00 = $54.00). BUCA's dispersion (168.58 - 102.00 = $66.58) is moderate. The table and chart below present the full breakdown.