CPT 99395: Preventive visit, established, age 18-39
What this code means, what it should cost, and how to dispute an overcharge.
Fair Price Reference
What is CPT 99395?
Your annual physical exam / wellness visit for an established patient age 18-39. This is the most commonly billed preventive code for young adults. Under the ACA, this should be covered at 100% by your insurance with no copay, coinsurance, or deductible when done by an in-network provider.
Typical setting: Primary care office, family medicine, internal medicine.
What CPT 99395 should cost
The Centers for Medicare & Medicaid Services (CMS) pays approximately $97 for CPT 99395 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 ($116–$175). Hospital chargemaster prices for CPT 99395 often range from $160 to $450 — a markup of 1.6x to 4.6x over Medicare.
Reality check: Medicare pays about $97 for 99395. Most insured patients should pay $0 under ACA preventive care rules. If you received a bill, check whether both a preventive and office visit code were charged.
Common overcharges on CPT 99395
The #1 billing trap: your provider bills 99395 (the physical) AND a separate office visit code (usually 99213 or 99214) for the same appointment. This means you expected a free annual physical but get a surprise $150-$400 bill for the 'sick visit' portion. Unless you brought up a brand-new, complex health problem during your physical, the separate charge may not be justified.
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 99395 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 ($146), 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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