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CPT 99396: Preventive Medicine Visit for Established Adults 40–64
Headline: CPT code 99396 defines the periodic preventive visit for established adults aged 40–64.
Lead: CPT code 99396 represents a comprehensive preventive medicine reevaluation and management visit for established patients between the ages of 40 and 64. This code captures age-appropriate history, physical exam, counseling, risk-reduction interventions, and ordering of screening or diagnostic tests. It is a key code for primary care preventive services and contributes to population health efforts focused on middle-aged adults.
Why it matters nationally: Preventive visits in this age group are central to early detection of chronic disease, cancer screening, and cardiovascular risk management. CPT code 99396 is widely used across outpatient primary care and factors into quality reporting and preventive care benchmarks.
Key payers covered: Analysis includes major national payers: Aetna, Blue Cross Blue Shield, Cigna Health, United Healthcare, and Medicare.
What readers will learn: The publication outlines the clinical context of CPT code 99396, payer coverage considerations, common associated ICD-10 diagnosis codes used with the service, related CPT preventive codes for other age bands, and typical settings where the service is delivered. It also summarizes common modifiers seen with outpatient preventive visits and associated clinician taxonomies for billing alignment.
Scope: National-level coverage and clinical context; payer-specific policy details are summarized where available. Data not available in the input for service-line financial benchmarks.
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Billing Code Overview
CPT code 99396 describes a periodic comprehensive preventive medicine reevaluation and management visit for an established adult patient aged 40 through 64 years. The service includes an age-appropriate history, physical examination, counseling, anticipatory guidance, risk-factor reduction interventions, and ordering of laboratory or diagnostic procedures as appropriate.
Service type: Established patient preventive medicine visit
Typical site of service: Office or outpatient clinic setting for primary care (family medicine or internal medicine)
National Reimbursement Benchmarks
For CPT 99396, BUCA’s average commercial rate is $150, serving as a practical midmarket benchmark against individual national payers. Blue Cross Blue Shield’s interquartile spread (P75–P25) is $58 ($168.6 − $110), Aetna’s spread is $114.3 ($214.3 − $97), Cigna’s spread is $92.3 ($193.6 − $101.3), and UnitedHealth Group’s spread is $98 ($216.6 − $116.8). These comparisons show Blue Cross Blue Shield with the tightest dispersion and Aetna with the widest, while UnitedHealth Group and Cigna sit in between, indicating varied commercial negotiation compressions across payers relative to the BUCA average.
Mean and median positions reflect different central tendencies: UnitedHealth Group posts the highest mean at $173.2 and a median of $156.2, while Aetna and Cigna have means near $159.1 and $154, with medians of $142.6 and $138.3 respectively. Blue Cross Blue Shield’s mean is $140.9 with a median of $127.4, and BUCA’s mean remains $150; these figures illustrate how payer-specific centering and dispersion combine to create the national commercial rate landscape for this preventive visit code.