CPT 99396: Preventive visit, established, age 40-64
What this code means, what it should cost, and how to dispute an overcharge.
Fair Price Reference
What is CPT 99396?
Your annual physical / wellness exam for an established patient age 40-64. This is the most common preventive visit code for middle-aged adults and typically includes age-appropriate screening discussions (cancer, cardiovascular, diabetes).
Typical setting: Primary care office, family medicine, internal medicine.
What CPT 99396 should cost
The Centers for Medicare & Medicaid Services (CMS) pays approximately $110 for CPT 99396 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 ($132–$198). Hospital chargemaster prices for CPT 99396 often range from $180 to $550 — a markup of 1.6x to 5x over Medicare.
Reality check: Medicare pays about $110 for 99396. Should be $0 copay under ACA preventive care rules when in-network. If you got a bill, the provider likely added a separate office visit code.
Common overcharges on CPT 99396
Double-billing with a same-day office visit (99213/99214) is extremely common for this age group because patients 40-64 are more likely to have existing conditions the provider addresses briefly during the physical. Unless a significant NEW problem was diagnosed and managed during the visit, the separate E&M charge is often improper.
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 99396 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 ($165), 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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