AI-generated ICD-10 and CPT codes from clinical notes — Medical Coding Online
Preventive E/M Codes by Age
Preventive medicine evaluation and management services are coded based on the patient's age, not by time or medical decision making. These codes cover comprehensive preventive visits for established and new patients.
| CPT Code | Age Group | Patient Type |
|---|---|---|
| 99381 | Infant (younger than 1 year) | New patient |
| 99382 | Early childhood (1–4 years) | New patient |
| 99383 | Late childhood (5–11 years) | New patient |
| 99384 | Adolescent (12–17 years) | New patient |
| 99385 | 18–39 years | New patient |
| 99386 | 40–64 years | New patient |
| 99387 | 65+ years | New patient |
| 99391–99397 | Same age groups | Established patient |
Medicare Annual Wellness Visit (AWV)
The Medicare Annual Wellness Visit (AWV) is distinct from a traditional preventive visit — it is not a head-to-toe physical examination. The AWV focuses on developing or updating a personalized prevention plan based on risk factors and a health risk assessment.
- G0402 — Initial Preventive Physical Exam (IPPE/'Welcome to Medicare') — once per beneficiary
- G0438 — Annual Wellness Visit, initial (first AWV) — once after IPPE or after enrollment
- G0439 — Annual Wellness Visit, subsequent — each year after G0438
- AWV elements: health risk assessment, vital signs, cognitive assessment, depression screening
- AWV does NOT include a full physical exam — distinguish clearly from 99387
- No cost-sharing for Medicare beneficiaries for AWV
Billing Preventive + Problem-Oriented Visit Same Day
When a patient comes in for a preventive visit but has a new or chronic problem addressed during the same encounter, both a preventive code and an E/M code can be billed — with modifier 25 on the E/M code.
- Preventive code (e.g., 99395) + E/M code (e.g., 99214-25) on same date
- Modifier 25 required on the E/M — indicates significant, separately identifiable service
- Document both components separately in the note
- E/M must be for a problem clearly distinct from the preventive visit
- Some commercial payers do not pay both — check payer policy
- Copay typically applies only to the E/M portion, not the preventive visit
Common Preventive Screening CPT Codes
Many preventive screenings are billed separately from the preventive visit itself. These are commonly performed during the preventive encounter but have their own CPT or HCPCS codes.
| Service | CPT/HCPCS Code | Frequency Limit |
|---|---|---|
| Colorectal cancer screening (colonoscopy) | G0121 or 45378 | Once every 10 years (Medicare) |
| Mammography, screening | G0202 or 77067 | Once every 12 months |
| Cervical cancer screening (Pap) | G0101 | Every 1–3 years per guidelines |
| Bone density (DXA) | 77080 | Every 2 years (Medicare) |
| Annual depression screening | G0444 | Once per year |
| Diabetes screening | G0108, G0109 | Once per year |
Common Preventive Care Coding Errors
Preventive care is a high-error area due to the complexity of age-based codes, Medicare-specific AWV codes, and the rules around billing preventive and problem-oriented visits together.
- Billing 99387 (comprehensive preventive E/M) instead of G0439 (AWV) for Medicare patients
- Missing modifier 25 on E/M when billed same day as preventive visit
- Billing AWV more than once per year (G0438 only once per lifetime)
- Unbundling screening services already included in the preventive visit per payer policy
- Incorrect age group code (99395 vs. 99396 for 40–64 vs. 65+)
- Not documenting the distinct nature of the E/M problem from the preventive visit
How AI Streamlines Preventive Care Billing
AI-powered medical billing tools automatically identify the correct preventive visit code based on patient age and history, detect AWV eligibility, flag modifier 25 requirements, and validate screening frequencies against payer policies.
- Auto-select correct preventive CPT code from patient age and payer
- Detect Medicare AWV eligibility (G0438 vs. G0439 based on history)
- Flag when modifier 25 is needed for same-day E/M
- Validate screening codes against annual frequency limits
- Alert when IPPE (G0402) has or hasn't been used
- Prevent preventive code denials with payer-specific rules
Frequently Asked Questions
- What is the difference between an Annual Wellness Visit and a preventive physical exam?
- A preventive physical exam (99385–99387 or 99395–99397) is a comprehensive head-to-toe examination covered by commercial insurance. The Medicare Annual Wellness Visit (G0438/G0439) is NOT a physical exam — it is a structured risk assessment and prevention planning visit. Many patients expect a 'physical' but what Medicare covers is the AWV. Billing 99387 for a Medicare patient expecting an AWV is both a coding error and a patient satisfaction issue.
- Can I bill a sick visit and a preventive visit on the same day?
- Yes, if both are medically necessary and separately documented. Use the preventive visit code (e.g., 99395) plus the E/M code (e.g., 99213) with modifier 25 appended to the E/M code. The modifier 25 indicates the E/M was a significant, separately identifiable service beyond the preventive visit. However, some commercial payers do not reimburse both on the same day — always verify payer policy.
- How often can Medicare patients have an Annual Wellness Visit?
- Medicare covers the Initial AWV (G0438) once — it must be at least 12 months after the initial IPPE (Welcome to Medicare visit, G0402) or after the beneficiary's first Medicare Part B effective date. Subsequent AWVs (G0439) can be performed once every 12 months after the initial AWV. The key distinction is that G0438 and G0439 cannot both be billed in the same calendar year, and G0402 can never be repeated.
- Is a screening colonoscopy billed differently than a diagnostic colonoscopy?
- Yes. Screening colonoscopies for Medicare patients use HCPCS codes G0121 (average risk) or G0105 (high risk), while diagnostic colonoscopies use CPT 45378. The distinction is important because screening colonoscopies have no cost-sharing for Medicare patients under the ACA's preventive services provisions. However, if a polyp is removed during what started as a screening colonoscopy, the claim may convert to a diagnostic/therapeutic procedure with different cost-sharing rules.
- What screenings are included in a Medicare Annual Wellness Visit without additional billing?
- The AWV itself includes: a health risk assessment, vital signs (height, weight, BMI, blood pressure), cognitive impairment assessment, depression screening (PHQ-2 or similar), review of functional ability, fall risk assessment, and personalized prevention plan. These components are bundled into G0438/G0439 — you cannot bill separately for the depression screening (G0444) if it was done during the AWV itself. Separate billing applies only when a screening is done at a different encounter.