CPT Code 99394: The Complete 2026 Billing Guide for Adolescent Preventive Visits

What Is CPT Code 99394?

CPT code 99394 is the preventive medicine evaluation and management code for a periodic comprehensive well visit for an established patient aged 12 through 17 years. It is one of the highest-volume codes in pediatric billing and covers the annual adolescent checkup that includes an age-appropriate history, physical examination, anticipatory guidance, and the ordering of any laboratory or diagnostic procedures.

Age range: 99394 applies strictly to established patients aged 12 years 0 months through 17 years 11 months on the date of service. A patient who turns 12 the day of the visit bills under 99394, not 99393. A patient who turns 18 before the visit date moves to 99395.

New vs. established: 99394 is the established patient code. Its new patient equivalent is 99384. A patient is generally considered established if they have been seen by a provider in the same specialty and group practice within the past three years.

Medicare status: 99394 carries a Status Indicator of N on the Medicare Physician Fee Schedule, meaning Medicare assigns RVUs but does not separately reimburse for the service. The vast majority of 99394 claims are billed to commercial payers, Medicaid, and CHIP plans, which is the standard payer mix for pediatric practices.

What CPT Code 99394 Means

CPT code 99394 describes a periodic comprehensive preventive medicine reevaluation and management service for an established patient who is an adolescent aged 12 through 17 years. The American Medical Association maintains this code as part of the preventive medicine E/M code family, which spans from 99381 through 99397.

The word periodic is doing real work in that definition. It means the visit is a scheduled reevaluation, not the patient’s first encounter with the practice. That is the dividing line between 99394 (established, periodic) and 99384 (new, initial). In a pediatric practice, 99394 is the code your billers will use for every returning adolescent’s annual well visit, from the 12-year checkup through the 17-year checkup.

One question we hear constantly from pediatric practice managers is whether 99394 can be billed when the patient technically qualifies as established but has not been seen in two or three years. The answer depends on the three-year rule. If the patient has been seen by any provider in the same group and specialty within the past three years, they remain established and 99394 applies. If they have not been seen in over three years, they may qualify as a new patient and the practice should evaluate whether 99384 is the correct code instead.

Where 99394 Fits in the Preventive Code Family

The preventive medicine E/M codes are organized by two variables: whether the patient is new or established, and the patient’s age on the date of service. Here is how 99394 sits within the established patient series that pediatric practices use daily.

CPT Code	Patient Type	Age Range	Description
99391	Established	Under 1 year	Infant preventive visit
99392	Established	1 to 4 years	Early childhood preventive visit
99393	Established	5 to 11 years	Late childhood preventive visit
99394	Established	12 to 17 years	Adolescent preventive visit
99395	Established	18 to 39 years	Young adult preventive visit

The new patient equivalents follow the same age bands: 99381 (under 1), 99382 (1 to 4), 99383 (5 to 11), 99384 (12 to 17), and 99385 (18 to 39). The only difference between a new and established preventive code is whether the patient meets the three-year established patient definition.

For a broader overview of how pediatric billing works across all visit types, see our guide on how to find the right pediatric medical billing service.

What Is Included in a 99394 Visit?

A visit billed under CPT code 99394 covers a comprehensive preventive encounter for an adolescent. The American Academy of Pediatrics Bright Futures Periodicity Schedule outlines the clinical components expected at each well visit age, and for the 12 through 17 age band, those components are more involved than many practices realize.

The visit must include all of the following to support a 99394 claim:

• Comprehensive age-appropriate history. This covers medical, family, and social history updated for the adolescent’s developmental stage. For patients 12 and older, the history should include private time with the adolescent to address topics the patient may not disclose in front of a parent or guardian.
• Complete physical examination. A head-to-toe examination appropriate for the developmental stage, including growth measurements, BMI calculation, vital signs, and a sexual maturity rating where clinically indicated.
• Anticipatory guidance and counseling. Age-appropriate guidance on topics such as nutrition, physical activity, substance use, sexual health, mental health, internet safety, and driving safety. This is not optional filler; it is a required component of the preventive visit.
• Risk factor reduction interventions. Screening and intervention for behavioral and environmental risk factors including depression screening (PHQ-A), substance use screening, and sexually transmitted infection risk assessment where appropriate.
• Ordering of laboratory or diagnostic procedures. Review and ordering of any age-appropriate labs or screenings. For adolescents, the AAP recommends lipid screening, anemia screening, and sexually transmitted infection screening at specified ages.

In our experience matching pediatric providers with billing partners, one of the most common documentation gaps we see on 99394 claims is the absence of documented anticipatory guidance. The provider performs the counseling but does not chart it with enough specificity for the claim to withstand an audit. Strong billing partners flag these gaps before the claim goes out.

Which ICD-10 Codes Pair With CPT 99394?

CPT 99394 is a procedure code that describes what the provider did. The ICD-10 diagnosis code describes why. For a standard adolescent well visit, two primary ICD-10 codes apply.

ICD-10 Code	Description	When to Use
Z00.129	Encounter for routine child health examination without abnormal findings	Standard well visit, no problems identified
Z00.121	Encounter for routine child health examination with abnormal findings	Well visit where abnormal findings are identified and addressed
Z23	Encounter for immunization	Linked to vaccine product and administration codes, not to 99394 itself

A critical detail that causes denials: Z23 links to the vaccine product codes and the vaccine administration codes (90460, 90461, 90471, 90472), not to 99394. Linking vaccines to Z00.129 instead of Z23 is one of the most common pediatric billing errors, and it triggers rejections across most payers.

When a provider identifies an abnormal finding during the well visit, the primary diagnosis shifts from Z00.129 to Z00.121. If the abnormal finding requires additional workup that constitutes a separately identifiable E/M service, the practice bills a problem-oriented E/M code (such as 99213 or 99214) alongside 99394, with modifier 25 appended to the problem-oriented code.

How to Bill 99394 With Modifier 25

Modifier 25 is the most important modifier in pediatric preventive billing, and it is the one most frequently misused. When a provider performs a well visit (99394) and also addresses a separate, significant problem during the same encounter, the practice can bill both codes on the same date of service.

The rules for billing 99394 alongside a problem-oriented E/M code are straightforward, but getting any one of them wrong results in a denial:

• Attach modifier 25 to the problem-oriented E/M code, not to 99394. The preventive code stands alone. The modifier flags the sick visit as a separately identifiable service.
• Link each code to its own diagnosis. 99394 links to Z00.121 (since an abnormal finding was addressed). The problem-oriented E/M code links to the specific ICD-10 code for the condition diagnosed, such as J06.9 for an upper respiratory infection or L70.0 for acne vulgaris.
• Document both services fully. The note must support the preventive visit components and, separately, the history, examination, and medical decision-making for the problem-oriented service. A single blended note that does not distinguish between the two will not survive an audit.

Here is a practical scenario. A 14-year-old established patient comes in for a well visit. During the examination, the provider diagnoses new-onset asthma and initiates a treatment plan. The claim would include 99394 linked to Z00.121, plus 99214-25 linked to J45.20 (mild intermittent asthma, uncomplicated). Both services are documented separately in the encounter note.

The biggest issue we see providers run into with modifier 25 is documentation. The clinical work gets done, but the note reads as one undifferentiated visit. When the payer reviews the claim, it cannot distinguish the preventive service from the problem service, and the problem-oriented code gets denied.

How Much Does CPT 99394 Reimburse?

Reimbursement for CPT 99394 varies significantly by payer, contract terms, geographic location, and plan design. Because 99394 carries a Status Indicator of N on the 2026 Medicare Physician Fee Schedule, Medicare does not separately reimburse the code. However, the assigned RVUs still matter because many commercial payers and self-funded plans base their preventive visit rates on the Medicare RBRVS framework.

Factor	Detail
Work RVU	1.75
Medicare Status	N (RVUs assigned, not separately payable by Medicare)
2026 Conversion Factor	$33.4009 (CMS non-QP rate)
Calculated Medicare Non-Facility	Approximately $119 (national average, before GPCI)
Commercial Payer Range	$82 to $212 depending on payer and geography

Across the billing companies we vet, a recurring pattern separates the practices that collect well on preventive visits from those that do not: the ones that collect well verify eligibility before the visit, confirm the patient has not already used their annual preventive benefit with another provider, and check whether the payer requires a specific diagnosis code format. The practices that leave money behind skip one or more of those steps and discover the problem only after the denial arrives.

For Medicaid-enrolled adolescents, 99394 is reimbursed under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which is a federal mandate. Medicaid EPSDT rates vary by state, but the visit itself is a covered benefit in all 50 states, and the provider must use Z00.121 or Z00.129 as the primary diagnosis for EPSDT claims.

Common 99394 Billing Mistakes and How to Fix Them

Every pediatric practice encounters the same handful of 99394 billing errors. The practices that catch them do so at the front end, before the claim goes out, not weeks later when the denial arrives. Here are the six mistakes that cost practices the most revenue on adolescent preventive visits.

1. Wrong age-band code. Billing 99393 for a patient who has turned 12, or billing 99395 for a patient who has not yet turned 18. The patient’s age on the date of service controls the code, every time. A 12-year-old billed under 99393 will be denied.
2. Using a problem-oriented E/M code instead of a preventive code. Some billers default to 99213 or 99214 for all office visits. A well-child checkup requires a preventive medicine code. Billing 99213 for an annual well visit undercodes the service and may trigger an audit if the documentation describes a comprehensive preventive encounter.
3. Linking vaccine codes to Z00.129 instead of Z23. Vaccine product codes (90649, 90685, etc.) and their administration codes (90460, 90461, 90471, 90472) must be linked to ICD-10 code Z23, not to the well visit Z-code. This mismatch is one of the most common pediatric claim denials.
4. Missing modifier 25 on same-day E/M. When the provider addresses a separately identifiable problem during the preventive visit, modifier 25 must be appended to the problem-oriented E/M code. Omitting the modifier results in a denial of the problem visit or, worse, the preventive visit.
5. Insufficient documentation of anticipatory guidance. The preventive visit must document each required component, including counseling. Payers conducting post-payment audits look specifically for documented anticipatory guidance content. A note that says only “anticipatory guidance provided” without specifics may not hold up.
6. Billing 99394 for a new patient. 99394 is strictly an established patient code. A new adolescent patient requires 99384. Submitting 99394 for a patient the practice has never seen will be denied.

Providers often come to us after months of watching preventive visit denials accumulate without a clear cause. When we help them look at the denial data, the pattern almost always traces back to one or two of these six errors running uncorrected through every claim batch.

What Is the Difference Between 99394 and 99384?

CPT 99394 and 99384 both describe a comprehensive preventive medicine visit for an adolescent aged 12 through 17. The only difference is patient status.

• 99384 is the new patient code. It is used when the adolescent has not been seen by any provider in the same specialty and group practice within the past three years.
• 99394 is the established patient code. It is used when the adolescent has been seen by any provider in the same specialty and group practice within the past three years.

The clinical documentation requirements are identical for both codes. The distinction is purely administrative: has this patient been seen before? In a pediatric practice with a stable patient panel, 99394 will outnumber 99384 by a wide margin because most adolescents returning for annual checkups are established patients.

One nuance worth noting: the new-vs-established determination applies at the group level, not the individual provider level. If a pediatrician leaves the practice and a new provider takes over the patient, that patient is still established as long as the group and specialty have not changed.

How to Bill Vaccines Alongside 99394

Vaccines administered during a 99394 visit are billed separately. The preventive visit code covers the well visit itself, not the immunizations. Pediatric practices must submit three separate types of codes for each vaccine given during an adolescent well visit.

• The vaccine product code identifies the specific vaccine administered. Examples for the 12 to 17 age group include 90651 (HPV, 9-valent), 90734 (meningococcal conjugate), 90715 (Tdap), and 90620 (meningococcal B). Each product code links to ICD-10 Z23.
• The administration code covers the act of giving the injection. For physicians or qualified healthcare professionals providing counseling, use 90460 for the first component and 90461 for each additional component. For administration without physician counseling, use 90471 for the first injection and 90472 for each additional injection. These also link to Z23.
• The preventive visit code (99394) covers the well visit and links to Z00.129 or Z00.121. It is billed independently of the vaccine codes.

Across the billing companies we vet, an area where we consistently see revenue leaking is vaccine administration coding. Practices using 90471/90472 when they should be using 90460/90461 (because the physician provided counseling) leave reimbursement on the table. The 90460 series typically reimburses at a higher rate. Confirm your major payer’s preference before defaulting to one pattern across the board.

Medicaid, CHIP, and EPSDT Coverage for 99394

For pediatric practices where Medicaid and CHIP represent 40% to 60% of the patient population, understanding how 99394 is reimbursed under these programs is essential.

The EPSDT benefit (Early and Periodic Screening, Diagnostic and Treatment) is a federal mandate that requires state Medicaid programs to cover comprehensive preventive services for all beneficiaries under age 21. CPT 99394 falls squarely within the EPSDT screening category. All state Medicaid programs reimburse 99394 as an EPSDT-qualifying service, but the rates, frequency limits, and documentation requirements vary by state.

Key billing rules for EPSDT claims using 99394:

• Primary diagnosis: Z00.121 or Z00.129 must be listed as the primary diagnosis code on EPSDT claims. Some states require the EPSDT screening indicator on the claim form as well.
• Frequency: The AAP Bright Futures schedule recommends annual well visits for adolescents. Most state Medicaid programs follow this schedule, but some allow additional visits based on medical necessity.
• Documentation: EPSDT claims require documentation that all screening components were provided. A visit that omits a required screening element (such as a developmental or depression screening) may not meet EPSDT requirements, even if the preventive visit code is otherwise supported.

In our experience matching pediatric providers with billing partners, Medicaid claim management is one of the top three reasons practices seek an outsourced billing solution. Each state has its own nuances around EPSDT billing, prior authorization for follow-up services, and vaccine program integration (VFC vs. private stock), and keeping up with those rules across multiple states is a full-time job in itself.

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