Billing for preventive care visits can be confusing. There are very few clear guidelines on how to bill specific preventive medicine evaluation and management (E/M) services and their required documentation. One such code is CPT code 99394, which is frequently used in pediatric practices.
Due to limited guidance, many billers make mistakes while filing claims for code 99394. That’s why we have created this comprehensive guide on how to use 99394 effectively.
So, let’s start.
CPT Code 99394 – Description
CPT code 99394 is officially defined as:
Comprehensive preventive medicine reevaluation and management service for an established patient, specifically for an adolescent (12-17 years old).
99394 is specifically used to bill adolescent preventive care visits. These visits may include age-appropriate physical examination, counseling, interventions for risk reduction, and the ordering of appropriate laboratory or diagnostic procedures.
The words “established” and “adolescent” are essential to focus on. Under the CPT coding system, an established patient is someone who has received a face-to-face service within the last 36 months. Additionally, CPT code 99394 is only used for patients within the age group of 12-17 years.
Please note that 99394 is different from CPT 99384. 99384 is for new patients, while 99394 is used for established patients. The similarity between the two lies in the age group. Both codes are for patients aged 12-17 years.
Scenarios Where CPT Code 99394 is Applicable
Want to gain a better understanding of CPT code 99394? Here is how you can apply this procedural code in various situations:
Annual Physical Examinations
The most common scenario for using CPT 99394 is the annual physical examination for established adolescent patients. These visits typically include growth monitoring, developmental assessment, immunization review and administration, and discussion of age-appropriate health topics such as nutrition, exercise, and safety.
Well Visit with Additional Services
Another use case scenario for CPT code 99394 can be when a simple well visit requires additional services. Suppose a 15-year-old teenager visits a practice for a routine checkup. However, during the checkup, the physician identifies some seborrheic keratosis lesions on the skin. Although the lesions are harmful, he suggests removing them. In this case, the physician will bill the well visit using CPT code 99394 with modifier 25. Additionally, the removal of the lesions is billed separately via CPT code 17110.
Applicable Modifiers for CPT Code 99394
For conveying additional information, you can apply the following modifiers to CPT code 99394:
Modifier 25
Modifier 25 indicates that a significant, separately identifiable evaluation and management (E/M) service was performed by the same physician or other qualified health care professional on the same day as another procedure or service. So, as mentioned above, you can append modifier 25 with CPT 99394 when another distinct service is performed on the same day as the E/M visit.
Modifier 33
Modifier 33 indicates that a service was provided as a covered preventive service, typically under the Affordable Care Act (ACA). So, if the commercial payer covers the preventive E/M visit with the established patient aged 12-17, you can append modifier 33 to CPT code 99394.
CPT Code 99394 – Billing & Reimbursement Guidelines
For successful claims submissions and fair reimbursement, make sure to follow the guidelines below:
Check the Insurance Coverage
CPT code 99394 has a status code “N” on the National Physician Fee Schedule Relative Value Unit (RVU) File. The status indicator “N” means that Medicare does not cover the service or item.
When a medical service has this status indicator, it means:
- Medicare will not pay for this service.
- The service is included in the Medicare system for tracking purposes only.
- Healthcare providers can still bill for these services, but patients would be responsible for the full cost.
However, some private insurance companies, like Cigna and Aetna, cover the cost of code 99394 if performed as an annual wellness examination.
Meet the Documentation Requirements
Appending the relevant and accurate documentation with your claims is key to successful billing. Without the correct documentation and medical records, your claims will be denied. However, there are no specific guidelines on what documents and records should be included in wellness exams.
We recommend providing the following:
- Comprehensive age and gender-appropriate history, including past illnesses, surgeries, medications, allergies, family and social histories, etc.
- Complete physical examination, including blood pressure, vision screening, hearing screening, height, weight, BMI, etc.
- Assessment of growth and development.
- Immunization review and administration when indicated.
- Anticipatory guidance and counseling documentation.
- Risk factor assessment and intervention recommendations.
- Laboratory or diagnostic test ordering when appropriate.
Wrapping Up
CPT code 99394 is one of the most used codes in pediatric practices. It represents a detailed preventive medicine reevaluation and management service for an established patient who is 12-17 years old. Despite its frequent use in medical billing, many billers get it wrong, which leads to claim denials.
In this guide, we have simplified everything you need to know about CPT code 99394. We have tried to cover information on the code’s correct application, relevant modifiers, and billing rules. However, if you are still unsure about pediatric coding, consider using expert pediatric billing services from our team at MediBillMD.
