CPT 99395 Reimbursement Benchmarks & Policy | OpenPayer

Summary & Overview

CPT 99395: Comprehensive Preventive Medicine Reevaluation for Established Adults

CPT code 99395 is a key billing code for comprehensive preventive medicine reevaluation and management of established adult patients. This code is widely used across the United States to document and bill for annual wellness visits and preventive care, which are essential for maintaining patient health and identifying risk factors early. The service encompasses a thorough history and physical examination, counseling, anticipatory guidance, and the ordering of necessary laboratory or diagnostic tests, all tailored to the patient's age and gender.

Major national payers, including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, recognize and reimburse for services billed under CPT code 99395. Coverage policies for this code are central to preventive care strategies and impact millions of insured individuals. Readers will gain insight into payer coverage, clinical benchmarks, and policy updates relevant to preventive medicine services. The publication also provides context on how 99395 fits within the broader landscape of evaluation and management codes, highlighting its role in routine adult health maintenance.

This summary offers a comprehensive overview of the clinical and billing significance of CPT code 99395, including payer coverage and its importance in preventive medicine. It serves as a resource for understanding national trends and policy considerations related to preventive care for established patients.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareCPT 99395preventive medicineevaluation and managementoffice visitadult healthclinical benchmarkspolicy updatesmedical billingcomprehensive exam

CPT Code Overview

CPT code 99395 is designated for periodic comprehensive preventive medicine reevaluation and management of an established patient. This service includes an age and gender appropriate history, examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures. The typical site of service for this code is the office (non-facility), identified as Place of Service 11. As a preventive medicine service, 99395 is intended to support ongoing health maintenance and early detection of potential health issues in adult patients.

Clinical & Coding Specifications

Clinical Context

A typical patient scenario for CPT code 99395 involves an established adult patient, generally between the ages of 18 and 39, presenting to a physician's office for a periodic preventive medicine reevaluation. The visit includes a comprehensive review of the patient's medical history, a physical examination appropriate for age and gender, counseling on health maintenance, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures as indicated. The workflow typically starts with patient check-in, followed by the physician's assessment, counseling, and any necessary orders for screening tests. The visit is preventive in nature and not prompted by specific symptoms or complaints.

Coding Specifications

Modifiers:
- Modifier 25: Used when a significant, separately identifiable evaluation and management service is performed by the same physician on the same day as another procedure or service.
- Modifier 33: Used to indicate that the service provided is a preventive service.
Provider Taxonomies:

Taxonomy Code

National Reimbursement Benchmarks

Nationally, the mean rate for CPT code 99395 among commercial payers (BUCA) is $129.05, which is notably higher than typical Medicare rates for similar services, though Medicare data is not available in the input for this code. UnitedHealth Group has the highest mean rate at $162.53, while Aetna is the lowest among the listed commercial payers at $121.98.

Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Blue Cross Blue Shield shows the tightest range ($49.10), indicating less variability in contracted rates. In contrast, Cigna and UnitedHealth Group exhibit the widest dispersions ($91.33 and $90.83, respectively), reflecting greater variability in their national reimbursement rates.

The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Alaska's reimbursement rates for CPT code 99395 show a substantial spread between the 25th and 75th percentiles, particularly for Cigna, where the difference is $132.17. UnitedHealth Group also demonstrates a high rate spread of $24.67, while Aetna and Blue Cross Blue Shield have more moderate spreads. Compared to national averages, all payers in Alaska reimburse at much higher rates, with UnitedHealth Group's mean rate nearly $112 above its national benchmark.

The table and chart below present the full breakdown of mean rates and percentile distributions for each payer in Alaska, highlighting the significant variation and elevated payment levels relative to national figures.

Key Insights for Alaska

UnitedHealth Group is the highest paying payer for CPT 99395 in Alaska, with a mean rate of $274.89.
Cigna is the lowest paying payer, with a mean rate of $174.19.
All Alaska payer rates are significantly higher than their respective national averages, with UnitedHealth Group showing the largest deviation.

CPT 99391: Preventive Medicine Visit for Established Infant Patients

99397-PERIODIC-COMPREHENSIVE-PREVENTIVE-MEDICINE-REEVALUATION-AND

CPT 99397: Periodic Preventive Medicine Reevaluation for Established Adults

99393-PERIODIC-COMPREHENSIVE-PREVENTIVE-MEDICINE-REEVALUATION-AND

CPT 99393: Preventive Medicine Visit for Established Child (Ages 5-11)

99394-PERIODIC-COMPREHENSIVE-PREVENTIVE-MEDICINE-REEVALUATION-AND

CPT 99394: Preventive Medicine Evaluation for Established Adolescent Patients

99396-PERIODIC-COMPREHENSIVE-PREVENTIVE-MEDICINE-REEVALUATION-AND

CPT 99396: Periodic Preventive Visit for Established Adults 40–64

99392-PERIODIC-COMPREHENSIVE-PREVENTIVE-MEDICINE-REEVALUATION-AND

CPT 99392: Preventive Medicine Reevaluation for Early Childhood, Established Patient

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

National Reimbursement Benchmarks

The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.

National Mean Rates for CPT 99395 by Payer

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Mean Reimbursement Rates by Payer in Alaska for CPT 99395

Key Insights for Alaska

UnitedHealth Group is the highest paying payer for CPT 99395 in Alaska, with a mean rate of $274.89.
Cigna is the lowest paying payer, with a mean rate of $174.19.
All Alaska payer rates are significantly higher than their respective national averages, with UnitedHealth Group showing the largest deviation.

CPT 99391: Preventive Medicine Visit for Established Infant Patients

99397-PERIODIC-COMPREHENSIVE-PREVENTIVE-MEDICINE-REEVALUATION-AND

CPT 99397: Periodic Preventive Medicine Reevaluation for Established Adults

99393-PERIODIC-COMPREHENSIVE-PREVENTIVE-MEDICINE-REEVALUATION-AND

CPT 99393: Preventive Medicine Visit for Established Child (Ages 5-11)

99394-PERIODIC-COMPREHENSIVE-PREVENTIVE-MEDICINE-REEVALUATION-AND

CPT 99394: Preventive Medicine Evaluation for Established Adolescent Patients

99396-PERIODIC-COMPREHENSIVE-PREVENTIVE-MEDICINE-REEVALUATION-AND

CPT 99396: Periodic Preventive Visit for Established Adults 40–64

99392-PERIODIC-COMPREHENSIVE-PREVENTIVE-MEDICINE-REEVALUATION-AND

CPT 99392: Preventive Medicine Reevaluation for Early Childhood, Established Patient

`207Q00000X`	Family Medicine Physician
`208000000X`	Pediatrics Physician
`207R00000X`	Internal Medicine Physician

OpenPayer

Summary & Overview

CPT 99395: Comprehensive Preventive Medicine Reevaluation for Established Adults

CPT Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes

Related Diagnoses

Related CPT Codes

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes