CPT 99385: Preventive visit, new patient, age 18-39
What this code means, what it should cost, and how to dispute an overcharge.
Fair Price Reference
What is CPT 99385?
Initial preventive visit for a new patient age 18-39 — your first annual physical with a new doctor. This includes a comprehensive history, full physical exam, age-appropriate counseling, and risk factor assessment.
Typical setting: Primary care office, family medicine, internal medicine.
What CPT 99385 should cost
The Centers for Medicare & Medicaid Services (CMS) pays approximately $112 for CPT 99385 under the 2025 Physician Fee Schedule. This is what the federal government has determined is a reasonable payment for this service.
Private insurance typically pays 1.2–1.8x Medicare rates ($134–$202). Hospital chargemaster prices for CPT 99385 often range from $180 to $500 — a markup of 1.6x to 4.5x over Medicare.
Reality check: Medicare pays about $112 for 99385. Should be $0 under ACA preventive care when in-network. If billed, check for double-coding with an office visit E&M.
Common overcharges on CPT 99385
Because this is a new patient visit, the charge is higher than the established version (99395). Watch for the provider also billing a new patient E&M code (99203/99204) on the same date — the same Modifier 25 rules apply. The separate office visit is only valid for a significant, separately identifiable problem.
About Preventive billing
Preventive visit codes (annual physicals, well-child visits, wellness exams) cover a comprehensive head-to-toe evaluation at defined age intervals. Under the ACA, many preventive services must be covered at 100% with no cost-sharing when performed by an in-network provider — but billing errors can turn a free annual physical into a surprise bill.
Request visit notes. If the provider billed both a preventive code and an office visit code, the documentation must show a distinct, significant clinical problem addressed beyond the scope of the preventive visit. If the provider simply discussed an existing condition, refilled medications, or answered routine questions, the separate E&M charge is not justified.
How to dispute a CPT 99385 overcharge
- Request the itemized bill. You are entitled to a detailed line-by-line bill showing every CPT code billed. Ask in writing.
- Compare to Medicare allowable. If the charge exceeds 150% of Medicare ($168), you have grounds to dispute.
- Request documentation. For E&M codes, ask for the visit note. For procedures, ask for the operative report. The documentation must justify the code billed.
- Send a formal dispute letter. Cite the specific discrepancy between the documentation and the code. Reference Medicare rates and NCCI edits where applicable.
- Follow up in writing. Give the provider 30 days to respond. If they don't, escalate to the state attorney general and insurance commissioner.
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