Preventive Medicine Billing Services

Preventive care is meant to find problems early, but the billing rules can be hard to follow. A visit that looks like a checkup to the patient may be a wellness exam, a screening or a problem visit to the payer. The label decides whether the patient owes a copay and whether the claim is paid.

Preventive medicine billing depends on age-based codes, specific diagnosis codes and payer lists of covered services. Counseling, screening and vaccines often appear on the same claim. Westmont Revenue Partners connects preventive medicine practices with vetted billing experts who know how to match services to the right codes, so claims reflect what was done and what the plan covers.

Who this is for

• Preventive medicine physicians and wellness-focused clinics
• Primary care practices with large annual exam volumes
• Employer and community wellness programs
• Clinics that provide screenings and risk-reduction counseling
• Practices that serve both commercial and Medicare patients

What gets billed

• Annual preventive exams by age group
• Medicare annual wellness visits
• Preventive counseling and risk-reduction visits
• Tobacco cessation counseling
• Alcohol misuse screening and counseling
• Depression screening
• Vaccine administration
• Cancer screening orders and related visits
• Blood pressure, cholesterol and diabetes screening
• Health risk assessments
• Same-day problem visits found during a checkup

Commonly billed codes

Code	Type	What it covers
99385	CPT	Preventive visit, new patient, ages 18 to 39
99395	CPT	Preventive visit, established patient, ages 18 to 39
99396	CPT	Preventive visit, established patient, ages 40 to 64
99397	CPT	Preventive visit, established patient, age 65 and older
99401	CPT	Preventive counseling, individual, short session
99402	CPT	Preventive counseling, individual, longer session
99406	CPT	Tobacco cessation counseling, short session
G0438	HCPCS	Medicare first annual wellness visit
G0439	HCPCS	Medicare subsequent annual wellness visit
G0442	HCPCS	Medicare screening for alcohol misuse
G0444	HCPCS	Medicare annual depression screening
Z00.00	ICD-10-CM	Routine adult health exam, no abnormal findings
Z00.01	ICD-10-CM	Routine adult health exam, with abnormal findings
Z23	ICD-10-CM	Encounter for a vaccine

Note

Codes are examples for orientation, not a complete list, and do not guarantee coverage or payment. Always check current code sets and payer policy.

Billing challenges in preventive medicine

Preventive versus problem visits. When a provider finds and addresses a new problem during a checkup, a separate problem visit may be billed. Billers check that the note shows extra work, then add modifier 25 where payers expect it.

Diagnosis code choice. Plans pay preventive services under the right diagnosis codes. Billers pair each screening with the correct diagnosis, and use the abnormal findings code only when documented.

Medicare is not a physical. The Medicare wellness visit is a risk review and planning visit, not a head-to-toe exam. Billers help clinics explain the difference to patients, so unexpected bills are fewer.

Frequency limits. Plans limit how often a patient can have an exam or screening. Billers check eligibility and the last service date before the visit.

Cost sharing surprises. Preventive services may be covered without cost sharing, but related services often are not. Billers prepare patient estimates and give front desk staff clear scripts.

Screening turns diagnostic. A routine screening that finds an issue may be billed differently by some payers. Billers know how each payer treats this and document the reason for the test.

Grandfathered and self-funded plans. Not every plan follows the same preventive rules. Billers verify benefits instead of assuming coverage.

How Westmont can help

• Matching you with vetted billing experts experienced in preventive and primary care billing
• End-to-end revenue cycle support from eligibility check to payment posting
• Denial management for preventive and screening claims
• Credentialing and payer enrollment support
• Help building claim checklists for annual exam workflows

Frequently asked questions

Why was my preventive visit billed as a regular visit?

Plans treat a visit as preventive only if it is coded as one and the diagnosis supports it. If the patient raised a new problem, a second problem-focused service may have been added. Patients may then owe cost sharing for that part. A biller can review the coding and explain the claim.

Can I bill counseling with a preventive visit?

Sometimes. Counseling codes are separate when the counseling goes beyond what is part of the routine exam and is documented with time. Many payers limit when they pay both. Check each payer's policy and the notes before billing. Time spent and the topic discussed should be recorded, and patient cost sharing may differ for counseling.

What is the difference between a physical and an annual wellness visit?

A physical, often called a preventive exam, includes a hands-on exam and history. The Medicare annual wellness visit focuses on a health risk review, a care plan and screening schedule. Medicare does not cover routine physical exams in most cases. Verify current Medicare rules.

How often can preventive exams be billed?

Many commercial plans cover one exam per year, and Medicare has its own schedule for wellness visits. Frequency rules and what counts as a year vary by plan. Billers check benefits and the last service date before the visit to avoid denials.

Do preventive services always have no copay?

Many plans cover recommended preventive services with no cost sharing, but not all. Grandfathered plans, services outside the recommended list and related diagnostic work may carry costs. Patients should check benefits, and practices should verify coverage before the visit so patients know what to expect.

Related billing services

• Family Medicine
• Internal Medicine
• Geriatrics
• Adolescent Medicine
• Occupational Medicine