CPT Code 99384: Adolescent Preventive Visit for New Patients Ages 12–17

CPT code 99384 is the adolescent well-visit CPT code for a new patient preventive visit at ages 12 through 17. It is the adolescent member of the 99381–99387 preventive medicine CPT codes. These codes are billed by age and patient status instead of   by time or medical decision-making. There are   two challenges that often come up: modifier 25 lands on the wrong code, and established patients get billed as new. This guide covers both, along with the ICD-10 pairings, same-day services, and reimbursement rules.

What CPT 99384 Covers

The 99384 CPT code description covers an age- and gender-appropriate history and exam, counseling and anticipatory guidance, risk factor reduction, and ordering any indicated labs or diagnostics.

New Patient Definition for CPT 99384

A patient is new if they have not received professional services from the physician, or from another physician of the same specialty and subspecialty in the same group, within the past three years (AMA CPT E/M guidelines). A 14-year-old seen by your partner two years ago for strep throat is an established patient, and the correct code is 99394. Nurse practitioners and physician assistants who work with the group’s physicians count as the same specialty, so a visit with the practice’s NP within three years also makes the patient established. 

Preventive vs. Problem-Oriented E/M

A visit scheduled to address a symptom or condition is a problem-oriented E/M (99202 through 99215), not 99384. The two can be billed together on the same day when both are documented, which is covered under the modifiers below. 

99384 Age Limit: Well Child Visit CPT Code by Age

Age	New patient	Established patient
Under 1 year	99381	99391
1–4 years	99382	99392
5–11 years	99383	99393
12–17 years	99384	99394
18–39 years	99385	99395
40–64 years	99386	99396
65 and over	99387	99397

The 99384 CPT code age limit is counted on the date of service. The line between 99383 and 99384 is the 12th birthday: a patient who turns 12 the day after the visit is billed under 99383. A patient who turned 18 the day before is billed under 99385.

99384 vs 99394

Same visit, different patient status. 99394 applies once the patient has seen a same-specialty provider in the group within three years, even for a sick visit. Patient status is set when the patient arrives, so once 99384 is billed, every visit in the next three years is established.

When to Report 99384

Report 99384 when the record shows all of the following for a new patient aged 12 through 17:

• Age- and gender-appropriate history (medical, family, social)
• Comprehensive physical examination
• Counseling and anticipatory guidance
• Risk factor reduction interventions
• Ordering of any indicated labs or diagnostics
• Immunization review

The HEADSS interview is part of the visit’s history and is not billed separately. Scored tools such as the PHQ-A and CRAFFT may be separately reportable when the instrument and score are documented. See the same-day table below. The AAP Bright Futures periodicity schedule includes a preventive visit at each age from 11 through 21. Payer frequency limits are a separate question. Some plans count by calendar year, and others require 365 days between visits, so check the plan’s benefit interval before scheduling.

Billing Scenarios

Annual Pediatric Checkup

A family relocates and brings their 13-year-old to your practice for a well visit. The provider documents full history, exam, growth assessment, anticipatory guidance, and an immunization review. Bill CPT code 99384 with Z00.129 (routine child health examination without abnormal findings).

Preventive Checkup for Sports

A 16-year-old new to the practice needs clearance for basketball. If the provider performs the full preventive visit and completes the form, bill CPT code 99384 with Z00.129 first and Z02.5 (encounter for examination for participation in sport) second. A form-only clearance without the comprehensive components does not support 99384.

Well Visit With a Same-Day Problem

A 15-year-old new patient comes for a well visit and asks about persistent acne. The provider completes the preventive exam and separately evaluates and treats the acne. Bill 99384 with Z00.121 (with abnormal findings) and L70.0, plus a new patient problem code (99202 through 99205) with modifier 25, leveled on the documented MDM. CPT guidance supports reporting both services as new patient codes when they happen at the same encounter (CPT Assistant, October 2006). Payer policies on same-day E/M services vary, so verify before submitting.

ICD-10 Codes for 99384

ICD-10-CM	Use
Z00.129	Routine child health exam, no abnormal findings
Z00.121	Routine child health exam with abnormal findings; code the finding too
Z02.5	Sports participation exam; list after Z00.12x when done at a well visit
Z23	Encounter for immunization, with vaccine administration codes
Z00.00 / Z00.01	Adult general exam; do not use for patients under 18

99384 Modifiers

99384 often carries no modifier, but same-day vaccines and Medicaid EPSDT rules can change that. 

Modifier 25

Modifier 25 goes in one of two places, depending on what else happens at the visit. 

Same-day problem: When a significant, separately identifiable problem is evaluated during the well visit, bill the problem E/M with modifier 25. The documentation has to show the extra work on its own.

Same-day vaccines: NCCI pairs the immunization administration codes 90460 to 90474 with the preventive codes 99381 to 99397 (CMS NCCI procedure-to-procedure edits). When vaccines are given at the well visit, append modifier 25 to 99384 so the payer can recognize both services, and add EP where the state Medicaid program requires it. The NCCI edit does not replace state EPSDT modifier rules. Many commercial plans apply the same edit, so check the plan’s policy. 

Modifier EP

State Medicaid programs may require modifier EP on preventive codes for beneficiaries under 21 to flag an EPSDT screening, and some also require the EPSDT indicator in box 24H of the CMS-1500. Check the state Medicaid agency or managed care plan instructions, since a missing EP or 24H indicator is a common Medicaid denial.

Modifier 33

AMA guidance reserves modifier 33 for services that are not inherently preventive. 99384 is inherently preventive, so most payers do not need it, though some commercial plans still request it to waive cost-sharing under the ACA. Follow the payer.

Same-Day Services

Code	Service	With 99384?
90460 / 90461	Immunization administration with counseling, plus vaccine product codes (90715, 90651, 90734)	Yes; modifier 25 on 99384 may be required where the payer applies the NCCI edit
96127	Brief emotional/behavioral assessment (PHQ-A)	Yes, payer permitting
96160 / 96161	Health risk assessment scored with a standardized instrument (patient-focused, such as CRAFFT / caregiver-focused)	Yes, payer permitting
99173 / 92551	Visual acuity / pure-tone hearing screen	Yes, payer permitting
99406 / 99407	Tobacco cessation counseling	Yes, when documented separately
99408	Alcohol/substance structured screening plus a brief intervention of 15 to 30 minutes	Only when a positive screen leads to a documented intervention of at least 15 minutes
36415	Venipuncture for labs drawn in the office	Yes; the lab test itself is billed by the performing lab
99401–99404	Preventive counseling	No; bundled into 99384

Reimbursement and Documentation

99384 Fee Schedule and Reimbursement

CPT code 99384 does not have a single commercial reimbursement rate. Payment varies by payer, plan, geographic market, participation status, and provider contract. Medicaid EPSDT reimbursement is determined by the applicable state program or managed care arrangement. Practices should verify their current contracted fee schedule and the patient’s preventive benefits before estimating payment.

Under the ACA, most non-grandfathered health plans must cover Bright Futures preventive services for children and adolescents without cost sharing when the patient sees an in-network provider (HealthCare.gov preventive services). Grandfathered plans are exempt, so confirm the patient’s benefits.  Coverage and benefits should still be verified with the patient’s plan. A problem visit billed with modifier 25 on the same day is not preventive, so the patient may owe cost-sharing for that portion.

Does Medicare Cover CPT 99384?

No. The 99381 through 99397 codes carry Medicare status indicator N (noncovered) on the Medicare Physician Fee Schedule. Medicare uses G0402, G0438, and G0439 for its own wellness visits. CMS still publishes relative value units for 99381 through 99397, and many Medicaid and commercial fee schedules are built from them. That is why RVU and dollar figures for 99384 appear online even though Medicare does not pay the code (CMS Medicare Claims Processing Manual, Chapter 12, Section 30.6.2). 

Documentation Requirements

• Date of birth and age on the date of service
• New-patient status confirmed against the three-year rule
• Medical, family, and social history, including a confidential adolescent section
• Examination by system
• Screening tools used and scores
• Anticipatory guidance topics and counseling
• Immunizations reviewed and given
• Labs or diagnostics ordered
• Separate note for any same-day problem

Confidential Services and the Parent’s EOB

Adolescents can consent to some services on their own under state law, such as STI testing or substance use counseling. The parent is usually the policyholder, though, so the explanation of benefits for those services goes to the parent. Under HIPAA, a patient can ask a health plan to send communications to an alternate address, and the plan must honor the request when the patient says disclosure could put them in danger (45 CFR 164.522(b)). When state law lets a minor consent to a service, the minor generally controls the health information for that service (45 CFR 164.502(g)(3)). Some states also limit what an EOB can show for sensitive services. Flag confidential services at check-in, confirm how the payer handles confidential communication requests, and document the consent basis in the record.

Common 99384 Denials and Fixes

Denial	Cause	Fix
Age inconsistent with code	Patient outside 12–17 on the date of service	Verify DOB at check-in; bill 99383 or 99385
New patient criteria not met	Seen in the group within three years	Bill 99394
Frequency exceeded	Visit fell inside the payer’s benefit interval (calendar year, 365 days, or other)	Check the last well-visit date and the plan’s frequency rule before scheduling
Missing or invalid diagnosis	Problem code used instead of Z00.12x	Sequence Z00.121 or Z00.129 first
Bundled with E/M	Modifier 25 missing from the problem code	Add 25 to the problem E/M, not to 99384
Preventive visit denied with vaccines	Payer applied an immunization edit and applicable modifier requirements were not met	Append modifier 25 to 99384 where the applicable edit and reporting requirements support it; add EP when required by the state Medicaid program
Medicaid EPSDT denial	Modifier EP or box 24H indicator missing	Follow the state Medicaid or managed care plan instructions

Getting 99384 Right

Clean 99384 billing starts with the correct age range, patient status, diagnosis coding, documentation, and modifier placement. If your practice is seeing denials on adolescent well visits, MedCare MSO’s pediatric billing services team handles preventive coding, EPSDT requirements, and denial management.

Clean 99384 claims come down to four checks: age on the date of service, the three year new patient lookback, the Z00.12x code that matches the findings, and which code carries modifier 25. For help with adolescent well visit claims, see MedCare MSO’s pediatric billing services.