What Medicare Pays vs. What You Might Be Charged

Category	Amount
Medicare Allowed Rate What Medicare approves for this service	$155.18
Typical Billed Amount What providers commonly charge	$230 – $500
Potential Markup How much more you might pay vs. Medicare rate	222% above Medicare

Why the difference? Providers set their own prices. Without insurance, you may be billed the full amount. Even with insurance, your co-pay is often based on the provider's charge — not the Medicare rate.

What CPT Code 99386 Covers

When you see a new doctor for your annual physical and you're between 40 and 64 years old, they'll use CPT code 99386 to bill for your visit. This code covers a comprehensive preventive medicine evaluation that's much more thorough than a regular office visit.

During this appointment, your doctor will review your complete medical history, perform a full physical examination, discuss age-appropriate screenings like mammograms or colonoscopies, and create a plan to keep you healthy. They'll also update your vaccinations and discuss lifestyle factors like diet, exercise, and stress management.

This code is specifically for preventive care, meaning you're not coming in because you're sick or have symptoms. It's all about maintaining your health and preventing future problems through early detection and healthy habits.

What to Expect on Your Medical Bill

When you receive your medical bill or explanation of benefits, you'll see CPT code 99386 listed for your annual physical. The Medicare reimbursement rate for this service is $155.18, but most healthcare providers charge between $230 and $500 for this comprehensive exam.

The actual amount you pay depends on your insurance coverage. Many insurance plans, including Medicare, cover annual preventive visits at 100% with no copay or deductible when you see an in-network provider. However, if additional services are performed during your visit that aren't considered preventive, you might see separate charges.

Your bill should clearly show CPT code 99386 as the primary service. If you see multiple codes from the same visit, make sure you understand what each one covers before paying.

How to Verify Your Billing is Correct

To check if you were billed correctly for CPT code 99386, first confirm that you're between 40 and 64 years old and that this was your first visit with this particular healthcare provider. If you've seen this doctor before for any reason, they should have used a different code (99396) for an established patient.

Review the charge amount on your bill. While fees vary by location and provider, charges significantly above $500 may warrant a question to your provider's billing department. Also verify that your visit was truly preventive in nature - if you discussed specific health concerns or symptoms, additional codes might be appropriate.

If you notice any errors or have questions about your bill, contact your healthcare provider's billing department first. They can explain the charges and make corrections if needed. If you're still unsure, your insurance company can also help you understand what should be covered under your plan.

Codes Often Confused With CPT 99386

CPT 99396 CPT 99385

Frequently Asked Questions

Is CPT code 99386 covered by insurance?

Yes, most insurance plans including Medicare cover annual preventive visits like CPT code 99386 at 100% with no copay when you use an in-network provider. This is considered essential preventive care under most health insurance plans.

What's the difference between CPT codes 99386 and 99396?

CPT code 99386 is for new patients aged 40-64 getting their first comprehensive physical with that provider. CPT code 99396 is for established patients in the same age group who have seen that doctor before.

How much should I expect to pay for CPT code 99386?

Healthcare providers typically charge between $230 and $500 for CPT code 99386. However, if you have insurance and use an in-network provider, you likely won't pay anything out of pocket since preventive visits are usually covered at 100%.