CPT 99396: Established Patient Wellness Visit, Age 40–64

Commercial payers pay $150 on average nationally for this procedure.

CPT code 99396 describes a periodic comprehensive preventive medicine visit for an established adult patient aged 40–64, providing an age‑appropriate history, physical examination, counseling/anticipatory guidance, risk‑factor reduction interventions, and ordering of appropriate preventive or diagnostic services; service type: preventive/wellness visit; typical site of service: office or outpatient clinic for primary care (family or internal medicine).

For related coverage guidance, see recent payer policy updates: DRG Newborn Inpatient Stays - Facility, Pediatric Preventive Screening, Pediatric Preventive Screening.

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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.

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CPT 99396: Established Patient Wellness Visit, Age 40–64

Commercial payers pay $150 on average nationally for this procedure.

For related coverage guidance, see recent payer policy updates: DRG Newborn Inpatient Stays - Facility, Pediatric Preventive Screening, Pediatric Preventive Screening.

Customize your policy alerts

Sign up for cpt 99396 policy alerts

Get alerted when payer policies referencing 99396 are released or updated.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

National Reimbursement Benchmarks

National Payer Mean Reimbursement Rates

Clinical & Coding Specifications

Clinical Context

A 52-year-old established female patient presents to her primary care office for a routine preventive health visit. She has no new complaints but requests review of preventive screenings and chronic disease risk factors. The visit is scheduled as a periodic comprehensive preventive medicine reevaluation for an established patient between ages 40 and 64 and is billed with 99396.

The clinical workflow begins with check-in and updating of medical, family, and social history. Vital signs, weight, height, BMI calculation, and targeted screening questions (tobacco, alcohol, diet, exercise, sexual health, and mental health) are completed by nursing staff and documented in the chart. The provider performs an age-appropriate physical exam, documents counseling/anticipatory guidance (including cardiovascular risk reduction, cancer screening, and immunization review), and orders preventive tests as indicated (for example, screening mammogram, cervical cancer screening per guidelines, fasting lipids, or blood glucose). Any abnormal screening findings generate problem-focused follow-up or referral. The visit is documented as a preventive encounter using diagnosis code Z00.00 or Z00.01 (if abnormal findings are present), and screening codes such as Z13.6, Z12.31, or Z12.4 are added when specific screening services are ordered or completed.

Typical site of service is an outpatient primary care clinic (family medicine or internal medicine office). The service is provided by clinicians with Family Medicine taxonomy 207R00000X or Internal Medicine taxonomy 207RR0500X. Common payors for documentation and billing include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99394`	Periodic comprehensive preventive medicine reevaluation and management, established patient; adolescent (age 12 through 17 years)	Age-adjacent periodic preventive code for younger established patients; used when patient falls in adolescent age range instead of `99396`
`99395`	Periodic comprehensive preventive medicine reevaluation and management, established patient; 18-39 years	Age-adjacent periodic preventive code for younger adults; used when patient age is 18–39 instead of `99396`
`99397`	Periodic comprehensive preventive medicine reevaluation and management, established patient; 65 years and older	Age-adjacent periodic preventive code for older adults; used when patient age is 65+ instead of `99396`

Related Modifiers

10 rows

Modifier	Description	When to Use
25	CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…	- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
59	Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…	- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
24	Modifier 24 denotes an unrelated evaluation and management (E/M) service performed by the same physician or qualified healthcare professional during a postoperative global period. Per CPT guidance,…	- Use modifier 24 when you report an evaluation and management (E/M) service performed by the same physician or same-specialty group during a procedure’s postoperative global period that is unrelated…
76	Modifier -76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional, is appended when the same provider performs an identical, medically necessary procedure or…	- Use modifier -76 when the same physician or other qualified health care professional performs an identical procedure or service a second (or subsequent) time on the same date of service and the…
91	Modifier 91 — “Repeat Clinical Diagnostic Laboratory Test” — is appended when the exact same CPT laboratory test is performed more than once for the same patient on the same day because serial,…	- Use modifier 91 when the exact same CPT laboratory test is performed more than once on the same patient on the same date because serial or repeated testing is medically necessary to monitor…
22	Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…	- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
32	Modifier 32 (Mandated Services) indicates that a CPT-coded service was required by a third party—such as an insurer, school, state agency, or court. The AMA defines it as denoting services mandated…	- Use Modifier 32 when a service or procedure was explicitly mandated by a third party (for example an insurer requiring a second opinion, a school requiring a sports physical, a state agency or…
95	Modifier 95 indicates that a service was provided via synchronous, real‑time audio‑video telehealth rather than in‑person. Per CMS, AAPC and professional associations, append modifier 95 to claim…	- Use modifier 95 to indicate a service was furnished via synchronous, real‑time audiovisual telehealth (a live audio‑video conference between patient and provider) rather than in‑person. - Pair…
26	Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…	- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…
53	Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…	- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…

Related Provider Taxonomies

8 rows

Taxonomy Code	Specialty	Notes
207R00000X	Internal Medicine Physician	A physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults…
207RR0500X	Rheumatology Physician	An internist who treats diseases of joints, muscle, bones and tendons. This specialist diagnoses and treats arthritis, back pain, muscle strains, comm…
163WC1600X	Continuing Education/Staff Development Registered Nurse	Nursing Service Providers · Registered Nurse
207RA0000X	Adolescent Medicine (Internal Medicine) Physician	An internist who specializes in adolescent medicine is a multi-disciplinary healthcare specialist trained in the unique physical, psychological and so…
305S00000X	Point of Service	This product may also be called an open-ended HMO and offers a transition product incorporating features of both HMOs and PPOs. Beneficiaries are enro…
2083X0100X	Occupational Medicine Physician	Occupational medicine focuses on the health of workers, including the ability to perform work; the physical, chemical, biological, and social environm…
2088F0040X	Urogynecology and Reconstructive Pelvic Surgery (Urology) Physician	A subspecialist in Urogynecology and Reconstructive Pelvic Surgery is a physician in Urology or Obstetrics and Gynecology who, by virtue of education …
163WC1500X	Community Health Registered Nurse	Nursing Service Providers · Registered Nurse

Related ICD-10-CM Codes

5 rows

ICD-10-CM Code	Description
Z13.6	Encounter for screening for cardiovascular disorders
Z12.31	Encounter for screening mammogram for malignant neoplasm of breast
Z12.4	Encounter for screening for malignant neoplasm of cervix
Z00.00	Encounter for general adult medical examination without abnormal findings
Z00.01	Encounter for general adult medical examination with abnormal findings

Related Payer Policy Updates

Specialty: Pediatrics/Neonatology1 / 2

10 rows

Policy	Payer	Effective Date
DRG Newborn Inpatient Stays - Facility	Blue Cross Blue Shield - Maine	2026-10-01
Pediatric Preventive Screening	Oscar Health	2026-10-01
Pediatric Preventive Screening	Blue Cross Blue Shield - New Mexico	2026-09-04
Pediatric Oral Function Therapy	Ambetter Georgia	2026-08-01
Prescribed Pediatric Extended Care (for Kentucky Only)	UnitedHealthcare	2026-08-01
Pediatric Preventive Screening	blue cross blue shield - louisiana	2026-08-01
Pediatric Oral Function Therapy	Health Net	2026-08-01
Pediatric Oral Function Therapy (Coverage Criteria)	Ambetter Nevada	2026-08-01
Pediatric Oral Function Therapy	Arizona Complete Health	2026-08-01
Pediatric Oral Function Therapy	Health Net	2026-08-01

CPT 98004: Established Patient Telemedicine E/M Visit, 10+ Minutes

CPT-98006-ESTABLISHED-PATIENT-AUDIO-VIDEO-EVALUATION-MANAGEMENT-30MIN

CPT 98006: Established Patient Telemedicine E/M, Moderate Complexity

CPT-98007-ESTABLISHED-PATIENT-TELEHEALTH-HIGH-COMPLEXITY-40-MIN

CPT 98007: Established Patient E/M via Synchronous Audio–Video, High MDM

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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Clinical & Coding Specifications

Clinical Context

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99394`	Periodic comprehensive preventive medicine reevaluation and management, established patient; adolescent (age 12 through 17 years)	Age-adjacent periodic preventive code for younger established patients; used when patient falls in adolescent age range instead of `99396`
`99395`	Periodic comprehensive preventive medicine reevaluation and management, established patient; 18-39 years	Age-adjacent periodic preventive code for younger adults; used when patient age is 18–39 instead of `99396`
`99397`	Periodic comprehensive preventive medicine reevaluation and management, established patient; 65 years and older	Age-adjacent periodic preventive code for older adults; used when patient age is 65+ instead of `99396`

Related Modifiers

10 rows

Modifier	Description	When to Use
25	CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…	- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
59	Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…	- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
24	Modifier 24 denotes an unrelated evaluation and management (E/M) service performed by the same physician or qualified healthcare professional during a postoperative global period. Per CPT guidance,…	- Use modifier 24 when you report an evaluation and management (E/M) service performed by the same physician or same-specialty group during a procedure’s postoperative global period that is unrelated…
76	Modifier -76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional, is appended when the same provider performs an identical, medically necessary procedure or…	- Use modifier -76 when the same physician or other qualified health care professional performs an identical procedure or service a second (or subsequent) time on the same date of service and the…
91	Modifier 91 — “Repeat Clinical Diagnostic Laboratory Test” — is appended when the exact same CPT laboratory test is performed more than once for the same patient on the same day because serial,…	- Use modifier 91 when the exact same CPT laboratory test is performed more than once on the same patient on the same date because serial or repeated testing is medically necessary to monitor…
22	Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…	- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
32	Modifier 32 (Mandated Services) indicates that a CPT-coded service was required by a third party—such as an insurer, school, state agency, or court. The AMA defines it as denoting services mandated…	- Use Modifier 32 when a service or procedure was explicitly mandated by a third party (for example an insurer requiring a second opinion, a school requiring a sports physical, a state agency or…
95	Modifier 95 indicates that a service was provided via synchronous, real‑time audio‑video telehealth rather than in‑person. Per CMS, AAPC and professional associations, append modifier 95 to claim…	- Use modifier 95 to indicate a service was furnished via synchronous, real‑time audiovisual telehealth (a live audio‑video conference between patient and provider) rather than in‑person. - Pair…
26	Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…	- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…
53	Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…	- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…

Related Provider Taxonomies

8 rows

Taxonomy Code	Specialty	Notes
207R00000X	Internal Medicine Physician	A physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults…
207RR0500X	Rheumatology Physician	An internist who treats diseases of joints, muscle, bones and tendons. This specialist diagnoses and treats arthritis, back pain, muscle strains, comm…
163WC1600X	Continuing Education/Staff Development Registered Nurse	Nursing Service Providers · Registered Nurse
207RA0000X	Adolescent Medicine (Internal Medicine) Physician	An internist who specializes in adolescent medicine is a multi-disciplinary healthcare specialist trained in the unique physical, psychological and so…
305S00000X	Point of Service	This product may also be called an open-ended HMO and offers a transition product incorporating features of both HMOs and PPOs. Beneficiaries are enro…
2083X0100X	Occupational Medicine Physician	Occupational medicine focuses on the health of workers, including the ability to perform work; the physical, chemical, biological, and social environm…
2088F0040X	Urogynecology and Reconstructive Pelvic Surgery (Urology) Physician	A subspecialist in Urogynecology and Reconstructive Pelvic Surgery is a physician in Urology or Obstetrics and Gynecology who, by virtue of education …
163WC1500X	Community Health Registered Nurse	Nursing Service Providers · Registered Nurse

Related ICD-10-CM Codes

5 rows

ICD-10-CM Code	Description
Z13.6	Encounter for screening for cardiovascular disorders
Z12.31	Encounter for screening mammogram for malignant neoplasm of breast
Z12.4	Encounter for screening for malignant neoplasm of cervix
Z00.00	Encounter for general adult medical examination without abnormal findings
Z00.01	Encounter for general adult medical examination with abnormal findings

Related Payer Policy Updates

Specialty: Pediatrics/Neonatology1 / 2

10 rows

Policy	Payer	Effective Date
DRG Newborn Inpatient Stays - Facility	Blue Cross Blue Shield - Maine	2026-10-01
Pediatric Preventive Screening	Oscar Health	2026-10-01
Pediatric Preventive Screening	Blue Cross Blue Shield - New Mexico	2026-09-04
Pediatric Oral Function Therapy	Ambetter Georgia	2026-08-01
Prescribed Pediatric Extended Care (for Kentucky Only)	UnitedHealthcare	2026-08-01
Pediatric Preventive Screening	blue cross blue shield - louisiana	2026-08-01
Pediatric Oral Function Therapy	Health Net	2026-08-01
Pediatric Oral Function Therapy (Coverage Criteria)	Ambetter Nevada	2026-08-01
Pediatric Oral Function Therapy	Arizona Complete Health	2026-08-01
Pediatric Oral Function Therapy	Health Net	2026-08-01

CPT 98004: Established Patient Telemedicine E/M Visit, 10+ Minutes

CPT-98006-ESTABLISHED-PATIENT-AUDIO-VIDEO-EVALUATION-MANAGEMENT-30MIN

CPT 98006: Established Patient Telemedicine E/M, Moderate Complexity

CPT-98007-ESTABLISHED-PATIENT-TELEHEALTH-HIGH-COMPLEXITY-40-MIN

CPT 98007: Established Patient E/M via Synchronous Audio–Video, High MDM

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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CPT 99396: Established Patient Wellness Visit, Age 40–64

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National Reimbursement Benchmarks

OpenPayer

CPT 99396: Established Patient Wellness Visit, Age 40–64

Sign up for cpt 99396 policy alerts

National Reimbursement Benchmarks

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related ICD-10-CM Codes

Related Payer Policy Updates

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related ICD-10-CM Codes

Related Payer Policy Updates

Related Codes

References

CPT 99396: Established Patient Wellness Visit, Age 40–64

Sign up for cpt 99396 policy alerts

National Reimbursement Benchmarks

CPT 99396: Established Patient Wellness Visit, Age 40–64

Sign up for cpt 99396 policy alerts

National Reimbursement Benchmarks

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related ICD-10-CM Codes

Related Payer Policy Updates

Related Codes

What clinical services are captured by CPT 99396?

Which ICD-10 diagnosis codes are typically billed with 99396?

Which CPT modifiers are commonly relevant when billing 99396?

What do the national payer reimbursement benchmarks indicate for 99396?

Which specialties, sites of service, and payers are associated with 99396?

References

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related ICD-10-CM Codes

Related Payer Policy Updates

Related Codes

What clinical services are captured by CPT 99396?

Which ICD-10 diagnosis codes are typically billed with 99396?

Which CPT modifiers are commonly relevant when billing 99396?

What do the national payer reimbursement benchmarks indicate for 99396?

Which specialties, sites of service, and payers are associated with 99396?

References