Is a yearly physical covered by insurance?
Usually yes, once a year, at no cost in network. A yearly physical (code 99395) is the preventive checkup for a patient aged 18 through 39, which is how a pediatric office bills the college age patients it keeps seeing. The bill that follows is almost always lab work or a problem raised during the exam.
100%
Preventive once a year in network
Turning 18
The code moves with the birthday. A patient who turns 18 before the appointment bills as 99395, even at the practice that has seen them since infancy.
Labs are separate
Screening labs ride the preventive benefit, diagnostic labs do not. The same blood draw is free or hits the deductible depending on the diagnosis on the order.
Copay creeps in
Mention a sore knee at the physical and a second line appears, usually 99213 with modifier 25. Covered, but it carries the plan's office copay.
Deductible first
Most high deductible plans still pay the physical at 100%, but anything tagged diagnostic hits the full deductible. One check before the visit shows how much is left.
What would a real check show for this patient's 99395?
Pick a sample plan and type your fee. This is the visibility a real-time check gives the desk for every actual patient, in under a second.
Eligibility readout · 99395
Sample- Coverage
- Active, preventive physical at $0 in network
- Frequency
- One physical per plan year, none used
- Patient share
- Type your fee to see it
Estimate from a sample plan. A real check reads the actual plan in under a second.
When 99395 is the right code
- Patient is 18 through 39 on the visit date
- The patient has been seen here within three years
- It is the yearly physical, not a problem visit
- Full exam, risk screening and counseling documented
Documentation payers expect
Documentation should include age, the exam, the risk factors reviewed and counseling given. A problem addressed at the same visit needs a separate note, its own diagnosis and modifier 25.
Why yearly physicals get denied
What happens after the yearly physical
The physical is usually free, and then the mail arrives. Blood work such as a cholesterol panel (80061) can come from an outside lab on its own claim. Anything found at the exam turns into a follow up visit, often 99213 or 99214, with a copay or coinsurance attached. Vaccines at this age use the plain shot fee (90471) next to the product line. A desk holding the deductible and copay answers those calls in one sentence.
99395, quick answers
Is an annual physical free?
On most plans in network, yes. 99395 is covered as preventive care with no copay and no deductible, as long as the visit stays preventive.
Why did the blood work cost money?
Screening labs follow the preventive benefit and diagnostic labs follow the deductible. The diagnosis on the order, not the visit, decides which one applies.
Can a physical and a sick visit happen on the same day?
Yes. The problem is billed as its own visit with modifier 25, and the patient owes the copay or coinsurance on that line only.
Does Medicare cover 99395?
No. Medicare does not pay 99395 at all. It buys a Welcome to Medicare visit and a yearly wellness visit under its own G codes, which are a different service with different documentation rules.
How does the desk see the deductible before the visit?
The check runs on the schedule before the patient arrives and shows plan status, deductible and out of pocket remaining, and copay or coinsurance where the payer reports them. First month free, then $2.50 a check.
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Every yearly physical verified before the patient walks in.
First month free, then $2.50 a check. No seat fees, no contract.
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Related: 99394 · 99385 · 99213
CPT is a registered trademark of the American Medical Association. This page is Valian's own plain-English summary for front-desk teams, not official CPT descriptor text, and is not billing or clinical advice. Coverage patterns are common plan behaviors; every plan differs. Verify benefits before the visit.