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Coding for Pediatrics 2024: A Manual for Pediatric Documentation and Payment (29th Edition)

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This year’s completely updated 29th edition of Coding for Pediatrics includes all changes in Current Procedural Terminology (CPT®) codes—complete with expert guidance for their application. The book’s recently updated vignettes and examples, as well as the many coding pearls throughout, provide added guidance needed to ensure accuracy and payment. Available for purchase at https://www.aap.org/Coding-for-Pediatrics-2024-29th-Edition-Paperback

Preventive Care

Payment for recommended preventive care services, preventive medicine evaluation and management services, icd-10-cm codes for preventive care visits, quality initiatives and preventive care, sports/camp preparticipation physical evaluations, immunizations, vaccines and toxoids, immunoglobulin immunization, national drug code, immunization administration for vaccines and toxoids, screening tests and procedures, hearing screening, vision screening, developmental screening and health assessment, developmental screening, emotional/behavioral assessment, health risk assessment, prevention of dental caries, application of fluoride varnish, counseling to prevent dental caries, other codes for prevention of dental caries, screening laboratory tests, preventive care provided outside the preventive visit, counseling and/or risk factor reduction, behavior change intervention, preventive medicine services modifier, reporting a preventive medicine visit with a problem-oriented visit, preventive and problem-oriented services: coding continuum, aap coding assistance and education.

  • AAP Pediatric Coding Newsletter

Immunization and Vaccines

Laboratory testing, national drug codes, online exclusive content at www.aap.org/cfp2024, quality measurement information, vaccines for children, 8: preventive services.

  • Published: October 2023
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"Preventive Services", Coding for Pediatrics 2024 : A Manual for Pediatric Documentation and Payment , Committee on Coding and Nomenclature, American Academy of Pediatrics, Linda D. Parsi, MD, MBA, CPEDC, FAAP

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Chapter Highlights

New Vaccines/Toxoids/Immunoglobulins

Coding for COVID-19 Immunization

Codes 90460 and 90461

Codes 90471–90474.

Coding for Counseling When Immunizations Are Not Carried Out

Vaccines for Children Program

Preventive Medicine, Individual Counseling Codes

Preventive Medicine, Group Counseling Codes

Other preventive medicine services.

Chapter Takeaways

Test Your Knowledge!

Specific diagnosis and procedure codes for preventive evaluation and management (E/M) services, including sports preparticipation physical evaluations

Coding for immunization administration (IA) services including vaccine/toxoid and immunoglobulin products

Assigning and linking proper diagnosis and procedure codes for all preventive services provided at an encounter

Reporting a significant E/M service to address a problem at the same encounter as a preventive E/M service

Preventive care is the hallmark of pediatrics. A pediatric preventive visit (also known as a health supervision visit or well-child visit) typically includes a preventive medicine E/M service and recommended screenings, tests, and immunizations. In this chapter, we discuss coding for combinations of preventive services.

The criterion standard of pediatric preventive care—the American Academy of Pediatrics (AAP) Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents , 4th Edition ( www.aap.org/en/practice-management/bright-futures )—is recognized in the Patient Protection and Affordable Care Act as requiring coverage, without cost sharing , by most health care plans.

Coverage of and appropriate payment for these pediatric preventive services should, at a minimum, reflect the total relative value units (RVUs) outlined for the current year under the Medicare Resource-Based Relative Value Scale (RBRVS) Physician Fee Schedule, inclusive of all separately reported codes for these services. Section 2713 of the Patient Protection and Affordable Care Act includes the following 2 sets of services that must be provided to children without cost sharing:

The standard set of immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved

Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA), which include

The AAP/Bright Futures periodicity schedule, “Recommendations for Preventive Pediatric Health Care” ( www.aap.org/en/practice-management/care-delivery-approaches/periodicity-schedule )

Recommendations of the Advisory Committee on Heritable Disorders in Newborns and Children

The AAP/Bright Futures periodicity schedule (refer to the insert or visit www.aap.org/en/practice-management/care-delivery-approaches/periodicity-schedule ) is a great tool for identifying recommended age-appropriate services, including many that may be reported with their own Current Procedural Terminology ( CPT ® ) or Healthcare Common Procedure Coding System (HCPCS) codes, when provided in conjunction with a comprehensive preventive service or on a separate date of service. The AAP Pediatric Preventive Services: Coding Quick Reference Card 2024 ( https://shop.aap.org/pediatric-preventive-services-coding-quick-reference-card-2024 ) combines these recommended services with the codes for each separately reportable service.

Although all recommended preventive services are covered, physicians and practice managers should be aware of health plan policies that may affect payment.

Specific diagnosis codes may be required to support claims adjudication under preventive medicine benefits. Be sure to link the appropriate diagnosis to each service provided (eg, Z71.3 , dietary counseling, may be linked to 99401 for a risk factor reduction counseling visit).

Some payers bundle certain services when the services are provided on the same date. For instance, some plans will not allow separate payment for obesity counseling on the same date as a well-child examination (at a health supervision visit) but will cover obesity counseling when no other E/M service is provided on the same date.

— It is beneficial to monitor and maintain awareness of the payment policies of the plans most billed by your practice.

— Most policies are available on payers’ websites with notification of changes provided in payer communications, such as electronic newsletters.

New in 2024! Add-on code #➕●99459 (pelvic examination) may be reported in addition to codes for preventive E/M, office E/M, and outpatient consultation services for the practice expense of performing the female pelvic examination. This code is not assigned work RVUs.

Well-child or preventive medicine services are a type of E/M service and are reported with codes 99381–99395 . Most health plans provide a 100% benefit (no patient out-of-pocket cost) for the 31 recommended preventive medicine service encounters when provided by in-network providers. Selection of the pediatric-specific codes 99381–99395 is based simply on the age of the patient on the date of the encounter and whether the patient is new or established to the practice ( Table 8-1 ).

In brief, an established patient has been seen (face-to-face, including via real-time audiovisual telehealth) by the physician or another physician of the same specialty and group practice within the past 3 years. Generally, other qualified health care professionals (QHPs; eg, advanced practice nurses, physician assistants/associates) are considered to be working in the same specialty as the physicians with whom they work. Refer to Chapter 7 for more information about new versus established patients.

A neonate who received hospital newborn care by the same physician or a physician of the same specialty and same group practice will be an established patient for post-discharge care in the office or other outpatient setting.

Figure 8-1. Preventive Visits by Patient Age as Recommended by the American Academy of Pediatrics/Bright Futures Periodicity Schedule

Most health plans limit the benefits for preventive medicine E/M services covered in a year by patient age. Refer to Figure 8-1 for an illustration of recommended preventive visits by age.

Immunizations, laboratory tests, and other special procedures or screening tests (eg, vision, hearing, or developmental screening) that have their own specific CPT codes are reported separately in addition to preventive medicine E/M services.

Most payers require reporting modifier 25 with the preventive medicine service when IA or other services are also performed and reported. Some payers do not pay for preventive screenings but may allow a physician to bill the patient. Contracts with payers may limit what may be billed to the patient.

A comprehensive history and physical examination must reflect an age- and a gender-appropriate history and examination.

The comprehensive history performed as part of a preventive medicine visit requires a comprehensive age-appropriate review of systems with an updated past, family, and social history. The history should also include a comprehensive assessment or history of age-pertinent risk factors.

Generally, the review of systems of a preventive medicine service is not a list of systems with pertinent positive and negative responses but, rather, a list of inquiries and patient responses for the areas of risk identified in preventive medicine guidelines as pertinent for patients of that age and gender. But some payers may require review of all systems regardless of age and gender (eg, required by some Medicaid plans under Early and Periodic Screening, Diagnostic, and Treatment benefits).

The AAP initial history questionnaire promotes documentation of preventive medicine services to support proper coding and appropriate payment. Forms can be ordered from the AAP by visiting https://shop.aap.org/initial-history-questionnaire-documentation-form . Additionally, some Medicaid programs have developed documentation templates for preventive services delivered in their Early and Periodic Screening, Diagnostic, and Treatment program.

Routine contraceptive counseling and management are considered part of the comprehensive preventive medicine E/M service when provided during the preventive visit. Contraceptive procedures (eg, insertion or removal of a device or implant, injection) are separately reported. Refer to International Classification of Diseases, 10th Revision, Clinical Modification ( ICD-10-CM ) category Z30 for diagnosis codes for contraceptive counseling and/or management.

A comprehensive physical examination is a multisystem examination that may include a routine pelvic and breast examination (when performed in the absence of specific symptoms of a problem) depending on the age of the patient and/or sexual history. Add-on code #➕●99459 (pelvic examination) may be reported in addition to the preventive E/M code for the practice expense of performing the female pelvic examination. This code is not assigned work RVUs.

— If the pelvic examination is performed to evaluate a gynecologic problem during a routine preventive medicine service, it may be appropriate to report a problem-oriented E/M service in addition to the preventive medicine service when additional physician work and requirements of the E/M code are met. Code 99459 may be reported in addition to codes 99202–99215 and 99242–99245 .

Medicaid programs have requirements for performing, documenting, and reporting certain services in their Early and Periodic Screening, Diagnostic, and Treatment programs. Modifier 52 (reduced services) may be required when the complete Early and Periodic Screening, Diagnostic, and Treatment service cannot be completed. Review your Medicaid plan policies for the specific documentation and reporting requirements for services to patients in these programs.

ICD-10-CM well-care diagnosis codes should be linked to the appropriate preventive medicine code ( 99381–99395 ). ICD-10-CM codes for well-child examinations include developmental, hearing, and vision screening.

For the purpose of assigning codes from this category, an abnormal finding is a newly discovered condition on screening or a known or chronic condition that requires attention because of exacerbation or inadequate control. Assign Z00.121 or Z00.01 and additional codes for documented abnormal findings. A stable chronic condition is not considered an abnormal finding.

An abnormal finding ICD-10-CM code (eg, Z00.121 ) can be linked to the procedure code for a normal screening test result; the abnormality will be identified with the appropriate ICD-10-CM code elsewhere on the claim so the payer will be aware that the abnormality is unrelated to the screening.

ICD-10-CM does not specify an age at which codes Z00.00 and Z00.01 are reported in lieu of codes Z00.121–Z00.129 . The age of majority varies by state and payer, who may or may not adopt the Medicare Outpatient Code Editor assignment of age limitations (29 days to 17 years) to codes Z00.121–Z00.129 , as indicated in many ICD-10-CM references.

Link routine health examination codes (eg, Z00.129 ) and Z23 (encounter for immunization) to the IA and immunization product codes when immunizations are administered at the preventive medicine encounter. ICD-10-CM instructs to report Z00.- first, followed by Z23 .

When reporting a routine child health examination without abnormal findings , report Z00.129 or Z00.00 and also a code for any stable or improving condition(s) addressed during the visit.

Like all children, children with chronic and complex health care needs must also receive periodic preventive care visits. Preventive medicine E/M services may take longer for these children. But preventive E/M services are not reported according to time, and prolonged service does not apply. Only report a separate E/M service on the date of a preventive E/M service when a problem is addressed that requires significant physician work (ie, medical decision-making [MDM] or time) and is separately identifiable in the documentation. A chronic medical condition that is not separately addressed with documentation of the required MDM or time spent addressing the condition does not support reporting both preventive care and a separate E/M service (eg, 99213 ).

Refer to Chapter 10 for information on care management for children with complex health care needs.

➤ A 9-year-old is seen for an established patient preventive medicine service . The child was seen 1 month ago for mild persistent asthma and reports no increase in asthma symptoms. But the child’s mother notes that the child’s rescue inhaler, which is carried to and from school, is nearing the expiration date. An age- and gender-appropriate preventive service is provided and documented. A refill prescription is ordered for the rescue inhaler. Diagnoses are well-child visit and stable mild persistent asthma. ICD-10-CM .  CPT .  Z00.129 (routine child health exam without abnormal findings) J45.30 (uncomplicated mild persistent asthma)  99393 (preventive medicine visit; age 5–11)  View Large Teaching Point: Because the asthma is not newly identified or failing to respond adequately to treatment, this is not an abnormal finding. But it is appropriate to report the code for the asthma that is still present in addition to code Z00.129 . In this example, the work of prescribing the asthma medication refill did not equate to a significant, separately identifiable E/M service.
➤ A 9-year-old was diagnosed 8 weeks ago with mild persistent asthma. The child presents today for a scheduled preventive service and follow-up visit. The child complains of increasing asthma symptoms and use of rescue inhaler. The patient’s medications and asthma control plan are revised, and the physician provides counseling to reinforce the avoidance of asthma triggers and management adherence. The age- and gender-appropriate preventive service is also provided and documented. The diagnoses are well-child visit with abnormal findings and mild persistent asthma with increasing symptoms. ICD-10-CM .  CPT .  Z00.121 (routine child health exam with abnormal findings) J45.31 (mild persistent asthma with acute exacerbation)  99393 (preventive medicine visit; age 5–11)  J45.31   99214 25 (established patient office visit with moderate level MDM)  View Large Teaching Point: Because the asthma was inadequately controlled, the routine health examination included an abnormal finding. A significant E/M service was provided to address the patient’s asthma control. For more on this topic, refer to Reporting a Preventive Medicine Visit With a Problem-Oriented Visit section later in this chapter. Code J45.31 is reported once on the claim but linked to each procedure code. If a vaccine had been administered at this encounter, modifier 25 would have also been appended to 99393 to signify that the preventive E/M service was significant and separately identifiable from the IA service.

Quality initiatives and measurement are becoming standard practice in health care. In pediatrics, many quality measures are associated with preventive care (eg, provision of one meningococcal vaccine on or between the patient’s 11th and 13th birthdays).

Quality measurement is required of health plans funded by government programs or offered through health exchanges under the Patient Protection and Affordable Care Act. These health plans must collect and submit Quality Rating System measure data to the Centers for Medicare & Medicaid Services (CMS). This entails collecting clinical quality measures, including a subset of the National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set (HEDIS) measures and a Pharmacy Quality Alliance measure. Physicians contracting with these plans may be asked to provide evidence that quality measures were met through claims data or medical records. Examples of HEDIS measures related to preventive care include

Percentage of members who turned 15 or 30 months old during the measurement year and who had 6 or more well-child visits with a primary care provider during the first 15 months after birth and 2 or more well-child visits from 1 day after the child turned 15 months old to turning 30 months old

Percentage of members 3 to 21 years of age who had at least 1 comprehensive well-care visit with a primary care provider or obstetrician-gynecologist during the measurement year

Members 3 to 17 years of age who had an outpatient visit with a primary care provider and who had the following services in the current year:

— Body mass index (BMI) percentile documentation

— Counseling for nutrition

— Counseling for physical activity

Certain preventive services, such as anticipatory guidance on healthy diet ( Z71.3 ) and exercise ( Z71.82 ), are components of the preventive medicine service and require no additional procedure coding for payment purposes. Associated diagnosis and procedure codes may, however, be reported to support quality reporting initiatives.

ICD-10-CM guidelines instruct that codes for BMI be reported when there is an associated, reportable diagnosis (eg, overweight, obesity). Yet some health plans still require this code to support quality measures in lieu of CPT performance measurement code 3008F (BMI, documented). Pediatric BMI codes in category Z68 include

Any chronic conditions reported may also support quality measurement and/or risk adjustment. Refer to Chapters 3 and 10 to learn more about risk adjustment and reporting chronic conditions.

Certain other procedure codes also support quality measurement. For example, submission of claims containing codes for meningococcal ( 90734 , #90619 ); tetanus, diphtheria, and acellular pertussis ( 90715 ); and 2 or 3 doses of human papillomavirus (HPV) vaccine ( 90651 ) provided to an adolescent before the patient’s 13th birthday is indicative of meeting the measure for the immunization of adolescents.

Some quality measures include information on reporting that a patient is ineligible for inclusion in the measure. For example, screening for depression ( Z13.31 ) is recommended for patients 12 years and older who were seen during the measurement year. But patients already diagnosed with depression or bipolar disorder are not included in the measurement.

It is important to note that a request for medical records is less likely when claims are submitted with procedure and diagnosis codes associated with pediatric quality measures.

Refer to Chapter 3 for more information on HEDIS and quality reporting.

Preventive medicine service codes ( 99381–99395 ) most accurately describe physical evaluations performed to determine participation eligibility. The physical evaluations are preventive and age appropriate in nature, and physicians offer counseling on topics such as appropriate levels of exercise or injury prevention. Yet the need for these services often arises after the child has had a yearly preventive medicine service, thereby rendering this service non-covered by some health plans, which allow only 1 preventive service per year. In this case, the parent may be billed if the payer contract allows because the service is non-covered.

When reporting sports or camp preparticipation physical evaluations for patients who have already received a recommended preventive medicine service, check the health plan’s policy on payment for these services and instructions for coding and billing. Under some plans, especially Medicaid plans, school and preparticipation physical evaluations may be covered even when the child has already had an annual preventive medicine service.

Office visit codes ( 99212–99215 ) may be used if the service is not comprehensive or a problem is evaluated during the service. Outpatient consultation codes ( 99242–99245 ) might be reported (when the health plan allows payment for these codes) if the coach or school nurse requested the physician’s opinion of a suspected problem (eg, exercise cough associated with reduced performance in cold weather). The medical record must include documentation of the written or verbal request as well as a copy of the written report with the physician’s opinion or advice that was sent back to the coach or school nurse when reporting a consultation.

If the preparticipation physical evaluation is incorporated into the annual health supervision visit, use Z00.121 or Z00.129 . Any problems or conditions addressed during the visit should also be reported. When a comprehensive preventive medicine service is not performed, Z02.5 (encounter for examination for participation in sports) and Z02.89 (encounter for other administrative examination) are reported. Code Z02.89 includes an examination for clearance to attend a camp. When reporting an examination for return to play after resolution of an illness or injury, report Z09 (encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) in addition to a code for the patient’s history of illness or injury, when indicated, and the code for the examination for clearance (eg, Z02.5 , Z02.89 ).

➤ A 15-year-old is seen at an established patient visit to evaluate fitness for return to play, specifically basketball, 2 weeks after testing positive for COVID-19 . A comprehensive preventive medicine service is not indicated because the patient’s most recent routine examination was 4 months before this visit. After evaluation and counseling, the physician completes the form releasing the patient to resume all activities, including basketball. Diagnoses are clearance for activities following resolved COVID-19. A level 3 office visit is documented. ICD-10-CM .  CPT .  Z09 (encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) Z86.16 (personal history of COVID-19) Z02.5 (encounter for examination for participation in sports)  99213 (office E/M with low level MDM or a minimum of 20 minutes total time on the date of the visit)  View Large Teaching Point: Because the determination to return to play required evaluation of the patient’s health status following illness (eg, ruled-out symptoms of postinfectious myocarditis), the visit is reported as a follow-up after completed treatment.

Codes in category Z02 are not reported in conjunction with codes for routine child health examination (category Z00 ). When clearance for participation is provided in conjunction with a routine child health examination, only the Z00 code is reported.

New in 2024!

Codes for COVID-19 vaccines and administration are simplified with 6 codes for vaccine products and a single administration code.

Codes 90380 and 90381 have been added for reporting a seasonal pediatric monoclonal antibody immunization against respiratory syncytial virus (RSV). These codes are found in the Immune Globulins, Serum or Recombinant Products section of CPT , and administration is reported with 96372 (injection, subcutaneous or intramuscular).

Vaccine, toxoid, and immunoglobulin services are reported with 2 families of CPT codes: one for the product and one for the services associated with administration of the product. Exceptions apply when patients receive vaccines through the Vaccines for Children (VFC) program. Refer to the Vaccines for Children Program later in this chapter for more details on VFC coding.

Codes 90476–90758 , 91304 , and 91318–91322 are used to report the vaccine or toxoid product only. They do not include the administration of a vaccine.

Appendix II provides a quick reference to codes, descriptors, and the number of vaccine components for each vaccine linked to the brand and manufacturer for each.

The word component refers to an antigen in a vaccine that prevents disease(s) caused by 1 organism.

The exact vaccine product administered needs to be reported to meet the requirements of immunization registries, vaccine distribution programs, and reporting systems (eg, Vaccine Adverse Event Reporting System), as well as for payment.

Codes may be specific to the product manufacturer and brand, schedule (ie, number of doses or timing), chemical formulation, dosage, and/or route of administration. When a vaccine code descriptor includes “when administered to” patients of certain ages, this is not an indication of the ages for which the product is licensed.

Codes for combination vaccines (eg, 90697 , diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine [DTaP-IPV-Hib-HepB]) are available, as are separate codes for single-component vaccines (eg, 90744 , Hep B).

It is not appropriate to code each component of a combination vaccine separately with separate vaccine product codes when a combination vaccine is administered. But if a combination vaccine was commercially available and a physician elected to administer the component vaccines given unavailability or another clinical reason, each vaccine product administered would be separately reported.

New codes 90380 and 90381 are used to report provision of an immunoglobulin or, more specifically, monoclonal antibody products to prevent RSV (nirsevimab). Report administration of the RSV monoclonal antibody seasonal immunization with code 96372 for the intramuscular (IM) injection.

✖ Do not report codes 90460–90461 for administration of the RSV immunization.

✖ Do not report 90380–90381 for palivizumab ( 90378 , RSV recombinant monoclonal antibody, each 50 mg).

The CPT Editorial Panel, in recognition of the public health interest in vaccine products, may publish new immunization product codes before US Food and Drug Administration (FDA) approval. The American Medical Association (AMA) uses its CPT site ( www.ama-assn.org/practice-management/cpt/category-i-vaccine-codes ) to provide updates of CPT Editorial Panel actions on new products. Once approved by the CPT Editorial Panel, vaccine/toxoid/immunoglobulin product codes are typically made available for release on a semiannual basis (July 1 and January 1). There is a 6-month implementation period from the initial release date (ie, codes released on January 1 are eligible for use on July 1; codes released on July 1 are eligible for use on January 1). Codes for products pending FDA approval are indicated with a lightning bolt symbol (⚡) that will be removed once the FDA status changes to “approved.” Refer to the AMA CPT site for the most up-to-date information on codes with this symbol. When a government agency has identified an urgent need for immunization services to address an emergent health issue (eg, COVID-19) and the FDA has granted the associated product an expedited review process, codes may be approved and released on an immediate (ie, outside the normal code consideration schedule) or rapid (ie, within the normal code consideration schedule but shortly after approval with an implementation date within 3 months of release) basis.

Before administering any new product or an existing product with new immunization recommendations, make certain that the CDC, in the Morbidity and Mortality Weekly Report , or the AAP, in Pediatrics , has endorsed the use or recommendations of the vaccine. You may also want to verify with a patient’s health plan that the immunization service is covered.

In the rare event that (a) a vaccine enters the market this year and is FDA approved, (b) recommendations for use are published by the CDC or AAP, and (c) no code exists for the specific vaccine, use 90749 (unlisted vaccine/toxoid) and list the specific vaccine given. Code 90399 is reported for an unlisted immunoglobulin product.

Many payers, specifically Medicare, Medicaid, other government payers (eg, Tricare), and some private payers, require the use of the National Drug Code (NDC) when reporting immunization product codes. The NDCs are universal product identifiers for medications, including immunization products. NDCs are found on outer packaging, product labels, and/or product inserts. Report the NDC from the outer packaging or product labels/inserts as required by the payer. For a fuller discussion of this type of reporting, refer to Chapter 1 .

NDCs are 10-digit, 3-segment numbers that identify the product, labeler, and trade package size. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 standards require an 11-digit code. Refer to Chapter 1 and Table 1-3 for more information, including how 10-digit codes are converted to the 11-digit format for reporting.

If you are not currently reporting vaccines with NDCs, be sure to coordinate the requirements with your billing software company. For more information on NDCs, visit www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm .

The administration of immunoglobulins, including nirsevimab and palivizumab (Synagis), is not reported with the IA codes. Refer to 96365–96368 , 96372 , 96374 , and 96375 . Subcutaneous or IM injection of immunoglobulins, including nirsevimab, is reported with 96372 (therapeutic, prophylactic, or diagnostic subcutaneous or IM injection). Refer to the October 2023 AAP Pediatric Coding Newsletter ™ article “Coding for Immunization Against Respiratory Syncytial Virus” ( https://coding.aap.org ) to learn more about reporting immunization against RSV.

CPT codes for vaccine IA are reported in addition to vaccine/toxoid code(s) 90476–90758 , 91304 , and 91318–91322 . There are 3 sets of IA codes.

90480 (administration of COVID-19 vaccine products)

90460 and 90461 (IA with counseling by a physician or QHP to child from birth through 18 years of age)

90471–90474 (IA to adult or to a child, from birth through 18 years of age, without counseling by a physician or QHP)

Clinical staff performing IA should document the administration as required by the National Childhood Vaccine Injury Act and recommended by the AAP in the “7 Rights of Vaccine Administration” ( www.aap.org/en/patient-care/immunizations/implementing-immunization-administration-in-your-practice/vaccine-administration ).

The COVID-19 vaccine products have been assigned specific codes by product and dosage. A single immunization administration code, 90480 , is used to report each COVID-19 vaccine administration. Other than 91304 (see descriptor below), all COVID-19 vaccine and vaccine administration codes developed prior to August 2023 were deleted on November 1, 2023.

Administration of COVID-19 vaccines includes counseling and time spent monitoring the patient after vaccine administration.

Note that, unlike other IA codes ( 90460 , 90461 ; 90471–90474 ), code 90480 is specific to administration of a COVID-19 vaccine product. Do not report 90480 for administration of a non–COVID-19 vaccine product. Administration and counseling are included in the service reported with 90480 regardless of patient age.

For examples of codes reported for immunization against COVID-19 and other diseases, refer to the following section:

When reporting 90460 and 90461 ,

Physicians or QHPs must provide face-to-face counseling to the patient and/or family (patient aged ≤18 years) at the time of the encounter for the administration of a vaccine. (Refer to the Codes 90471–90474 section later in this chapter for IA without physician counseling or to patients >18 years. Refer also to the Coding for Counseling When Immunizations Are Not Carried Out section later in this chapter.)

CPT defines a physician or other QHP as follows:

A “physician or other qualified health care professional” is an individual who by education, training, licensure/ regulation, facility credentialing (when applicable), and facility privileging (when applicable) performs a professional service within his/her scope of practice and independently reports that professional service. These professionals are distinct from “clinical staff.”

Clinical staff do not qualify to perform the counseling reported under 90460 and 90461 . Although state scope of practice may allow certain clinical staff to perform the service, it will not qualify them to report these codes. In the absence of counseling by a physician or QHP, administration services by clinical staff are reported with 90471–90474 . CPT defines clinical staff as follows:

A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service. Other policies may also affect who may report specific services.

When a private payer contract does not allow QHPs to report services under their own name and National Provider Identifier, check with the payer to determine the eligibility of these professionals to report immunization counseling ( 90460 , 90461 ) and report under the name and number of the supervising physician.

Documentation of immunization counseling should include a listing of all vaccine components with notation that counseling was provided for all listed components with authentication (electronic or written signature and date) by the physician or other QHP. Supply of the Vaccine Information Statement (VIS) without discussion of risks and benefits does not constitute counseling. Some payers require documentation of parent or caregiver questions or concerns that were addressed during counseling.

Code 90460 is reported for the first ( or only ) component of each vaccine administered (whether single or combination) on a day of service and includes the related vaccine counseling.

Code 90461 is reported only in conjunction with 90460 and is used to report the work of counseling for each additional component ( s ) beyond the first in a combination vaccine. (Refer to the Vaccines for Children Program section later in this chapter for reporting administration of vaccines containing multiple components to this program.)

Combination vaccines are vaccines that contain multiple vaccine components. Refer to Appendix II for the number of components in the most commonly reported pediatric vaccines.

IA codes include the physician or other QHP discussing risks and benefits of the vaccines, providing parents with a copy of the appropriate CDC VIS for each vaccine given, giving the vaccine, and observing and addressing reactions or adverse effects, as well as the cost of clinical staff time to record each vaccine component administered in the medical record and statewide vaccine registry and the cost of supplies (eg, syringe, needle, bandages).

Code 90460 is reported for each individual vaccine administered because every vaccine will have, at minimum, 1 vaccine component. For combination vaccines, 90461 is additionally reported for counseling on each additional component. No modifier is typically required for reporting multiple units of the IA codes. Most payers advise reporting multiple units of the same service on a single line of the claim. Individual payer guidance, however, may vary. The AAP continues to advocate to the CMS for increased RVUs for 90460 and 90461 .

Append modifier 25 when a significant, separately identifiable E/M service (eg, office or other outpatient service, preventive medicine service) is performed in addition to IA. If vaccines are given during a preventive medicine E/M service and another E/M service, both E/M services will need modifier 25 if required by the payer. Refer also to the Reporting a Preventive Medicine Visit With a Problem-Oriented Visit section later in this chapter.

➤ An adolescent presents for an influenza immunization. After you counsel the patient, clinical staff administer an intranasal quadrivalent influenza vaccine (LAIV) at the same encounter.

Report 90460 with 1 unit in addition to 90672 (LAIV). Code 90461 is not reported because the vaccine contains only 1 component (ie, protects against 1 disease). Link the vaccine and administration CPT codes to ICD-10-CM code Z23 on health insurance claims.

➤ A 6-month-old patient presents for an established patient well-baby visit. The physician (or QHP) provides and documents the preventive medicine E/M service. The physician counsels the caregivers about recommended immunization with rotavirus vaccine (RV5, third dose); diphtheria and tetanus toxoids and acellular pertussis, inactivated poliovirus, and Haemophilus influenzae type b vaccine (DTaP-IPV/Hib, third dose); pneumococcal vaccine (PCV15, third dose); and COVID-19 vaccine (Moderna, first dose). The parent/guardian is given the CDC VIS and consents; the nurse prepares the vaccine. The nurse administers each vaccine, documents the required information, and accesses and enters vaccine data in the statewide immunization registry. The patient is discharged home after the nurse confirms that there are no serious immediate reactions. ICD-10-CM .  CPT .  Z00.129 (encounter for routine child health examination without abnormal findings)  99391 25 (preventive E/M service, established patient; infant [age younger than 1 year])  Z00.129 Z23 (encounter for immunization)  90680 (rotavirus vaccine, pentavalent [RV5], 3 dose schedule, live, for oral use) 90700 (DTaP-IPV/Hib, for IM use) 90671 (PCV15, for IM use) 91321 (COVID-19, 25 mcg/0.25 mL dose, for IM use) 90460 × 3 90461 × 4 90480 × 1  View Large Teaching Point: Because the physician personally performed the counseling, 90460 is reported for IA of the initial component of the DTaP-IPV/Hib vaccine and for the single-component RV5 and PCV15 vaccines. Code 90460 is appropriate regardless of the route of administration. Code 90461 is reported for the 4 secondary components of the DTaP-IPV/Hib vaccine. Code 9048 0 is reported for IA of a COVID-19 vaccine. Payers that have adopted the Medicare National Correct Coding Initiative (NCCI) edits will require that modifier 25 be appended to 99391 to signify that it was significant and separately identifiable from the IA. (For more information on NCCI edits, refer to Chapter 2 .) ICD-10-CM code Z00.129 is reported first, followed by Z23 .

Codes 90471–90474 will be reported when criteria for reporting the 2 pediatric IA codes ( 90460 and 90461 ) have not been met. This occurs when either of the following circumstances are true:

The physician or QHP does not counsel the patient or family or does not document that the counseling was personally performed for each component of the vaccines administered.

The patient is 19 years or older.

The CMS assigned the following total RVUs (unadjusted for geographical location) in 2023 (2024 RVUs were not established at the time of this publication):

Appropriate reporting of 90460 and 90461 in lieu of 90471–90474 should result in higher payment based on reporting of multiple units of 90461 for each additional vaccine component versus reporting of 90472 and 90474 for each additional vaccine product.

Individual payers may or may not assign payment values based on the RVUs published by the CMS. (Administration of vaccines provided through the VFC program is paid differently. For more about the VFC program, refer to the Vaccines for Children Program section later in this chapter.)

When reporting codes 90471–90474 ,

Codes 90471–90474 are reported for each vaccine administered, whether single or combination vaccines.

Only one “first” IA code ( 90460 , 90471 , or 90473 ) may be reported per date of service.

The “first” IA code can be reported from either family or route of administration (eg, when a patient receives an immunization via injection and a second one via intranasal route, IA services can be reported with 90471 and 90474 or with 90473 and 90472 ).

If a physician personally performs counseling on one vaccine but not on another when given during the same encounter, IA will be reported with 90460 (and 90461 if appropriate) and either 90472 (IA, each additional vaccine via injection) or 90474 (IA, each additional vaccine via intranasal or oral route). The Medicare NCCI edits pair 90460 with 90471 and 90473 and, therefore, do not allow codes from the pairs to be reported on the same day of service by the same physician or physician of the same group and specialty.

For more information on vaccine administration, refer to the following examples and Appendix II :

➤ A 4-year-old patient who was recently seen as a new patient for clearance to attend preschool returns for influenza immunization, which was not available at the time of the previous visit . The service is scheduled with clinical staff only. The patient is noted to be in good health with no contraindications to the immunization per CDC guidelines. Next, the VIS and the antipyretic dosage for weight are reviewed with the father, who provides consent for the immunization. The influenza vaccine is administered, and the child is observed for immediate reactions before discharge. ICD-10-CM .  CPT .  Z23 (encounter for immunization)  90686 (influenza vaccine [IIV4], preservative free, 0.5 mL, IM) 90471 (IA, first injection)  View Large Teaching Point: Because counseling by a physician or QHP is not provided at this encounter, code 90471 is reported in lieu of 90460 .
➤ A 5-year-old established patient presented 2 weeks ago for her 5-year checkup and vaccines. At that appointment, her physician provided counseling for each recommended vaccine component and corresponding VISs. The patient’s mother asked that the vaccines be split, so only the DTaP and IPV vaccines were given at that encounter. The patient returns today and sees a nurse for an immunization-only visit to get the measles-mumps-rubella (MMR) and varicella vaccines. ICD-10-CM .  CPT .  Z23 (encounter for immunization)  90707 (MMR, live) 90471 (IA, first injection) 90716 (varicella vaccine) 90472 (IA, subsequent injection)  View Large Teaching Point: Services at this second visit did not include physician counseling, which is required to support use of 90460 and 90461 . Counseling for all vaccines occurred at the most recent encounter and all VISs were handed out, so only administration occurred today. IA of DTaP and IPV vaccines at the previous encounter would be reported with CPT codes 90460 × 2 and 90461 × 2 (in addition to the code for the 5-year preventive service) for services completed on that date.

Only report 90460 and 90461 when physician counseling is provided on the date of vaccine administration. If vaccine administration is delayed to another date when physician counseling is not provided, report 90471–90474 as appropriate. There is no separate procedure code for counseling without administration during a preventive medicine service.

➤ A 19-year-old established patient presents for a routine health examination. In addition to providing a preventive medicine service with no abnormal findings, the physician counsels the patient on the need for meningococcal serogroup B (MenB-4C) immunization. The vaccine is administered. ICD-10-CM .  CPT .  Z00.00 (encounter for general adult medical examination without abnormal findings)  99395 25 (preventive medicine service, established patient, 18–39 years old)  Z23 (encounter for immunization)  90620 (MenB-4C) 90471 (IA, first injection)  View Large Teaching Point: Because the patient is older than 18 years, 90460 cannot be reported even though the physician provided counseling for the vaccine provided. Code Z00.00 (encounter for general adult medical examination without abnormal findings) is reported for the age- and gender-appropriate preventive medicine E/M service. Code Z23 is reported for the encounter for immunization. ICD-10-CM does not instruct to report first a code for any routine adult examination, unlike for childhood examinations.

Pediatricians may counsel patients and caregivers on the need for immunization but either decide that immunization is contraindicated or do not receive the patient’s/caregiver’s consent to immunize at the current encounter.

When immunization counseling takes place at the time of a preventive E/M service (well-child visit) and does not result in administration, the counseling is not separately reported. (For a possible exception for services to Medicaid under state-defined benefits for stand-alone vaccine counseling, refer to the Stand-alone Counseling section later in this chapter.)

When the purpose of the encounter is immunization counseling and immunizations are not administered, preventive medicine counseling codes 99401–99404 (for further discussion, refer to the Counseling and/or Risk Factor Reduction section later in this chapter) may be reported according to the time spent in face-to-face counseling with the patient and/or caregivers.

— Codes for E/M services to address health problems (eg, 99202 ) may be reported in addition to 99401–99404 when preventive counseling is provided at the same encounter. Append modifier 25 (significant, separately identifiable E/M service) to the problem-oriented code (eg, 99202 25 ) when reporting both services at the same encounter.

When a payer does not pay for immunization safety counseling services reported with codes 99401–99404 , another E/M service (eg, office E/M service) may be reported according to the time spent on that date of service.

— Report ICD-10-CM code Z71.85 (encounter for immunization safety counseling) as the primary diagnosis. In addition, report the reason an immunization was not carried out, beginning with a code from ICD-10-CM category Z28 (immunization not carried out), and under-immunization status.

Under-immunization is reported with codes in subcategory Z28.3- .

Codes in subcategory Z28.3- should not be used for individuals who are ineligible for the COVID-19 vaccines, as determined by the health care professional. Additional codes in category Z28 are reported to indicate the reason for under-immunization status.

Contraindications to immunization are captured with codes in subcategory Z28.0- .

Other codes in category Z28 provide for reporting of immunization not carried out for patient reasons, caregiver refusal, or another specified reason.

The AAP offers additional resources for addressing refusal to vaccinate, including vaccine refusal forms in English and Spanish ( https://downloads.aap.org/DOPCSP/SOID_RTV_form_01-2019_English.pdf and https://downloads.aap.org/DOPCSP/SOID_RTV_form_01-2019_Spanish.pdf ).

Stand-alone Vaccine Counseling

The Medicaid program includes coverage for stand-alone vaccine counseling as part of an Early and Periodic Screening, Diagnostic, and Treatment benefit. In the context of this benefit, stand-alone vaccine counseling does not mean that the counseling was the only service provided. Stand-alone refers to counseling provided on a date when no IA takes place.

Individual Medicaid plan policies differ on how stand-alone vaccine counseling benefits are reported and the payment for the service. Some plans accept HCPCS codes G0310–G0315 and/or CPT codes 99401–99404 with modifiers EP (Early and Periodic Screening, Diagnostic, and Treatment service) and/or 59 (distinct service). It is imperative to verify the local plan’s benefit and reporting instructions for these services.

Refer to the September 2022 AAP Pediatric Coding Newsletter article “Did You Know? Medicaid and Children’s Health Insurance Program Early and Periodic Screening, Diagnostic, and Treatment Services and Vaccine Counseling” ( https://doi.org/10.1542/pcco_book221_document003 ) for more information and code descriptors for G0310–G0315.

➤ Parents of a 2-month-old established patient come to their physician’s office to discuss immunizations. To date, they have refused to have their infant immunized. Although the physician has discussed the need for vaccines during the infant’s previous visits, the parents indicate they have further questions. The physician spends 20 minutes counseling the parents about current recommendations, safety and efficacy of vaccines, and their importance in preventing disease. ICD-10-CM .  CPT .  Z71.85 (encounter for immunization safety counseling) Z28.3 (personal history of under-immunization status) Z28.82 (vaccination not carried out because of caregiver refusal)  99401 (risk-factor reduction counseling) or 99213 (office E/M, 20–29 minutes)  View Large Teaching Point: Because the CPT midpoint rule applies, 99401 is reported for service times between 8 and 22 minutes. Alternatively, when a payer does not pay for 99401 , established patient office E/M code 99213 is reported for 20 to 29 minutes of a physician’s or QHP’s total time on the date of the encounter that was directed to care of the individual patient. A Medicaid plan might provide benefits for this encounter by using G0313 (immunization counseling by a physician or QHP when the vaccine[s] is not administered on the same date of service for ages under 21, 16–30 mins time). But this is not true for all Medicaid plans.
➤ An 11-year-old girl (new patient) presents to a pediatrician for a preventive medicine service. In addition to the preventive E/M service with no abnormal findings, the physician discusses risks of the HPV vaccine and the disease for which it provides protection. The parent/guardian is given the CDC VIS. The parent/guardian consents; the nurse prepares to administer the vaccine. But the patient refuses to be immunized. The physician returns to the examination room and provides additional counseling, but the patient continues to refuse the vaccine. The patient’s mother wishes to discuss the decision with the child’s father and return on a later date. A follow-up appointment is scheduled. ICD-10-CM .  CPT .  Z00.129 Z28.21 (immunization not carried out because of patient refusal)  99383   View Large Teaching Point: Because no vaccine was administered, no charge for the product or the administration would be reported. Written procedures for documentation and reporting of expired and wasted vaccine doses may be required for vaccines provided under the VFC program. When the patient returns for follow-up, the codes reported will depend on the outcome of the encounter. If the vaccine is administered after additional physician counseling at the same encounter, 90460 will be reported in addition to the appropriate vaccine product code. If the patient returns for administration by clinical staff without additional counseling by a physician, 90471 will be reported in lieu of 90460 . Additional counseling at the follow-up physician visit that does not result in immunization may be reported with a preventive medicine counseling code ( 99401–99404 ) based on the physician’s face-to-face time with the patient. Do not report 99401–99404 on the same date as a preventive medicine E/M service (eg, 99383 ). Note that modifier JW (drug amount discarded/not administered to any patient) is typically inappropriate when no vaccine is administered to the patient. Modifier JW is used to report waste from a single-dose vial/package when the required patient dose is less than the available single-dose amount. Two claim lines report the amounts administered and wasted. Follow payer instructions for reporting wasted vaccines and use of modifier JW .

For more information, refer to the July 2020 AAP Pediatric Coding Newsletter article “Coding for Vaccines Not Administered” ( https://doi.org/10.1542/pcco_book195_document007 ).

The VFC program makes immunization services available to children, teens, and young adults up to 19 years of age who meet any of the following criteria: are enrolled in the Medicaid program (depending on the Medicaid managed care), do not have health insurance, have no coverage of immunizations under their health plan, or are American Indians or Alaska Natives. Vaccines are provided at no cost to the participating physician or patient, and payment is made only for administration of the vaccine.

If reporting the VFC product with administration codes and not the product code, data for the vaccine products administered must be captured for registry and quality initiatives. That can be accomplished by entering the vaccine codes with a $0 charge, if your billing system allows, and appending modifier SL (state-supplied vaccine) to the product code. But follow individual payer rules for reporting.

Providers are encouraged to use 90460 for administration of a vaccine under the VFC program unless otherwise directed by a state program. If 90461 is used for a vaccine with multiple antigens or components, it should be given a $0 value for a child covered under the VFC program. This guidance applies to Medicaid-enrolled VFC-entitled children as well as non–Medicaid-enrolled VFC-entitled children (ie, uninsured, underinsured, and American Indian or Alaska Native children) in certain circumstances. For more about VFC eligibility, visit www.cdc.gov/vaccines/programs/vfc/providers/eligibility.html .

Please be aware that some Medicaid programs have reporting rules that differ from those of VFC. Be sure to get this policy in writing from your Medicaid program and follow it to prevent denied payment. The AAP continues to advocate to the CMS to allow for recognition of and payment for component-based vaccine counseling and administration (ie, 90461 ). Under the current statute, administration can be paid only “per vaccine” and not per component.

Participants in the VFC program should be aware of program-specific guidance, including storage of VFC vaccines separate from privately purchased vaccines. For more information on the VFC program, visit www.cdc.gov/vaccines/programs/vfc/index.html .

Refer to “FAQ: Immunization Administration” at www.aap.org/cfp2024 for more discussion of coding for IA.

Recommendations for age-appropriate screening services are outlined in the AAP/Bright Futures periodicity schedule, “Recommendations for Preventive Pediatric Health Care” ( www.aap.org/en/practice-management/care-delivery-approaches/periodicity-schedule ), or in your state’s Early and Periodic Screening, Diagnostic, and Treatment plan.

When routine vision, developmental, and/or hearing screening services are performed in conjunction with a preventive medicine visit, the diagnosis code for a routine infant or child health checkup should be linked to the appropriate screening service. The services/codes listed are examples of services that could be used to screen a patient. Some payers have specific policies that outline covered screening tools based on age; know your payer policies. For example, past a certain age, 92567 (tympanometry) may not be covered under preventive services.

Some payer policies bundle certain screening services (eg, vision screening) into the preventive medicine E/M service. This bundling does not align with CPT instruction or NCCI edits. But some payers allow separate payment for screening services. Refer to the July 2022 AAP Pediatric Coding Newsletter article “Coding and Billing Basics: Ruling Out Misinformation” ( https://doi.org/10.1542/pcco_book219_document005 ) for an example of differing payer policies for preventive screening services and a discussion of possible lost revenue when billing is based on the most restrictive payer policy.

Audiometric tests require the use of calibrated electronic equipment, recording of results, and a written report with interpretation (eg, chart of hertz and decibels with pass/fail result for each ear tested and overall pass/fail result). Services include testing of both ears. If the test is applied to only 1 ear, modifier 52 (reduced services) must be appended to the code.

When hearing screening is performed in the physician office because of a failed screening in another setting (eg, school), report ICD-10-CM codes from category Z01.11- . Code Z01.110 is reported for a normal screening result following a failed screening. Code Z01.118 indicates a failed repeated screening. An additional code is reported to identify the abnormality found following the failed repeated screening.

Medicaid plans may provide specific hearing screening/testing coverage information and documentation forms/requirements. Follow the individual plan’s guidance for reporting these services and any failed attempts to screen (eg, an attempt to screen an uncooperative child).

Code 92551 (screening test, pure tone, air only) is used when the patient wears earphones and is asked to respond to tones of different pitches and intensities. This is a limited study.

Code 92552 (full pure tone audiometric assessment; air only) is used when the patient wears earphones and is asked to respond to tones of different pitches and intensities. The threshold (lowest intensity of the tone heard by the patient 50% of the time) is recorded for multiple frequencies.

Code 92558 (evoked otoacoustic emissions [OAEs] screening) is used when a probe tip is placed in the ear canal to screen for normal hearing function. Sounds that bounce back in low-intensity sound waves (ie, OAEs) are recorded and analyzed by computerized equipment and the results are automated.

Code 92583 (select picture audiometry) is typically used for younger children. The patient is asked to identify different pictures with the instructions given at different sound intensity levels.

Other commonly performed procedures include codes 92567 (tympanometry [impedance testing]) and 92568 (acoustic reflex testing, threshold portion). Both codes may, however, have limited coverage; check with payers.

Automated audiometry testing is reported with Category III codes 0208T–0212T . Verify individual payer payment policy before providing these services.

➤ George is a 16-year-old established patient presenting for a preventive service and clearance to participate in school sports. A complete preventive E/M service ( 99394 ) is provided. George has not received a hearing screening since he was 13 years old, so pure tone, air-only screening audiometry is performed ( 92551 ). No abnormalities are found, and George receives clearance to participate in sports. The ICD-10-CM code reported for each of the services is Z00.129 (encounter for routine child health examination without abnormal findings).
➤ Sally is a 6-year-old who failed a hearing screening at school and is referred to her pediatrician for additional evaluation. Sally’s parents indicate no prior concerns about her hearing, and risk factor assessment is negative. The pediatrician chooses to perform screening audiometry ( 92551 ), which produces typical results. The ICD-10-CM code reported is Z01.110 (encounter for hearing examination following failed hearing screening). If the MDM or total physician time (not including time of testing) supports a separate office or other outpatient E/M service, an E/M code is separately reported (eg, 99212 ).

Screening test of visual acuity ( 99173 ) must use graduated visual stimuli that allow a quantitative estimate of visual acuity (eg, Snellen chart).

— Code 99173 is reported only when vision screening is performed in association with a preventive medicine visit.

— Medical record documentation must include a measurement of acuity for both eyes, not just a pass or fail score.

Do not report 99173 when it is performed as part of an evaluation for an eye problem or condition (eg, examination to rule out vision problems in a patient presenting with problems with schoolwork) because the assessment of visual acuity is considered an integral part of the eye examination.

Instrument-based ocular screening ( 99174 , 99177 ) is used to report screening for a variety of conditions, including esotropia, exotropia, isometropia, cataracts, ptosis, hyperopia, myopia, and others, that affect or have the potential to affect vision. These tests are especially useful for screening infants, preschool patients, and those older patients whose ability to participate in traditional acuity screening is limited or very time intensive.

— Code 99177 specifies screening with an instrument that provides an on-site (ie, in-office) pass or fail result. The result should be documented.

— Code 99174 specifies the use of a screening instrument that incorporates remote analysis and report (by a physician located elsewhere).

— These screenings cannot be reported in conjunction with codes 92002–92700 (general ophthalmologic services), 99172 (visual function screening), or 99173 (screening test of visual acuity, quantitative) because ocular screening is inherent to these services. An AAP policy statement on instrument-based pediatric vision screening is available at https://doi.org/10.1542/peds.2012-2548 .

Vision screening performed with an automated visual evoked potential system is reported with 0333T . This code applies to automated screening via an instrument-based algorithm with a pass or fail result. A report of the result must be documented. Report 95930 only for comprehensive visual evoked potential testing with physician interpretation and report.

Retinal polarization scanning ( 0469T ) is used to detect amblyopia caused by strabismus and defocus. As with 99177 , results of each scan are generated on-site.

Standardized screening instruments (ie, validated tests that are administered and scored in a consistent or “standard” manner consistent with their validation) are used for screening and assessment purposes as reported by 96110 and 96127 . Health risk assessments that are patient focused ( 96160 ) are differentiated from those such as maternal depression screening that are caregiver focused ( 96161 ) for the benefit of the patient.

Structured screening for developmental delay is a universal recommendation of the “Recommendations for Preventive Pediatric Health Care.” At 18- and 24-month visits, specifically screen for autism spectrum disorder (ASD). Global developmental screening is recommended at 9-, 18-, and 30-month visits. When reporting these screenings, 96110 represents developmental screening with scoring and documentation per standardized instrument. ( Note: Screening results should be documented in the patient medical record.)

ICD-10-CM codes Z13.41 (encounter for autism screening) and Z13.42 (encounter for screening for global developmental delays [milestones]) may be used to track developmental screening measures of the Child Core Set for patients receiving benefits through their Medicaid and Children’s Health Insurance Program. Use of the Child Core Set is optional for state programs and physicians. Codes Z13.41 and Z13.42 may be reported at any encounter at which screening is performed (eg, with or without a preventive E/M service).

Is reported only for standardized developmental screening instruments. It is not reported when the pediatrician conducts an informal survey or surveillance of development as part of a comprehensive preventive medicine service (which is considered part of the history and is not separately billed).

Does not require interpretation and report (ie, includes scoring and documentation only).

Is not reported for brief emotional or behavioral assessment (eg, depression screening); refer to 96127 .

May be reported for each standardized developmental screening instrument administered. Medicaid Medically Unlikely Edits (MUEs) allow reporting of 3 screening instruments per date of service. If use of more than 3 instruments is clinically indicated and performed, 96110 is reported with 3 units billed on the first claim line and 96110 59 is billed with 1 unit for each additional instrument reported on a separate claim line.

➤ An 18-month-old girl presents to her primary physician for an established patient well-child examination. The mother is given standardized screening instruments for developmental status and ASD by clinical staff, who explain their purpose and how they should be completed. The nursing assistant scores the completed forms and documents the instruments used and scores of each in the child’s medical record. The physician interprets and documents the normal results of the instruments. The physician provides the recommended 18-month preventive E/M service ( 99392 ). The child will return for a scheduled 2-year-old preventive service. ICD-10-CM .  CPT .  Z00.129 (routine child health examination [≥29 days] without abnormal findings)  99392   Z13.42 (screening for delayed milestones) Z13.41 (autism screening)  96110 × 2  View Large Teaching Point: Code 96110 is reported with 2 units of service linked to ICD-10-CM codes Z13.41 (autism screening) and Z13.42 (screening for delayed milestones) to identify the reason for 2 units of service. Or, if required by a health plan, 96110 linked to Z13.41 and 96110 59 linked to Z13.42 are reported on 2 separate claim lines (1 unit per claim line). (For an illustration of how codes are linked on a claim form, refer to Figure 1-1 .)

Is reported for documentation and scoring of standardized emotional/behavioral assessment instruments. For further discussion of 96127 for reporting use of standardized instruments in diagnoses or management of emotional/behavioral conditions, refer to Chapter 12 .

Represents the practice expense of administering, scoring, and documenting each standardized instrument. No physician work value is included. Physician interpretation is included in a related E/M service.

Is not reported in conjunction with preventive medicine counseling/risk factor reduction intervention ( 99401–99404 ) or psychiatric or neurological testing ( 96130–96139 or 96146 ).

Can involve 2 or more separately reported instruments (eg, screening instruments for anxiety and depression). Note that MUEs limit reporting to 3 units per claim line. When reporting to payers adopting MUEs, additional units beyond the first 3 must be reported on a separate claim line with an NCCI modifier (eg, 59 , distinct procedural service). As always, documentation should support the appropriateness of the additional units of service.

Can be reported for standardized depression and anxiety instruments that are required under US Preventive Services Task Force (USPSTF) and Bright Futures recommendations (refer to the AAP/Bright Futures “Recommendations for Preventive Pediatric Health Care” [periodicity schedule] insert).

Alternatively, there is a HCPCS code for depression screening that some payers (particularly Medicaid or managed Medicaid plans) prefer in lieu of 96127 for annual depression screenings. If required, report G0444 (annual depression screening, 5–15 minutes) to those payers.

The code descriptor for G0444 includes “5–15 minutes.” Verify the payment policies of Medicaid plans that require G0444 , specifically noting any requirement to document time spent providing the depression screening service.

➤ A 12-year-old boy is seen for an established patient well-child examination at a health supervision visit. In addition to the preventive medicine service, the physician’s staff administers and scores 2 standardized instruments to screen for depression and anxiety. The physician reviews the scores, documents that the screening results are negative for symptoms of depression or anxiety, and completes the preventive medicine service. ICD-10-CM .  CPT .  Z00.129   99383   Z13.31 (encounter for screening for depression) Z13.39 (encounter for screening examination for other mental health and behavioral disorders)  96127 × 2  View Large Teaching Point: Codes Z13.31 and Z13.39 indicate that 2 screening instruments were used to screen for different conditions and may support quality measurement (eg, percentage of patients aged ≥12 years who were screened for depression). When a positive screening results in a diagnosed condition, report the preventive service with abnormal findings ( Z00.121 ) followed by the appropriate code for the diagnosed condition (eg, F32.0 , major depressive disorder, single episode, mild). When appropriate, a significant and separately identifiable E/M service to evaluate and manage the condition may be reported by appending modifier 25 to an office or other outpatient E/M code (eg, 99214 25 ). Documentation should clearly support the MDM of the separate service or, if billing according to time, the physician’s total time (not including the time spent providing the separately reported preventive medicine service and screening for depression) and a summary of the service provided (eg, education on the condition, questions answered, patient and/or caregiver concerns, management options discussed, plan of care). Link the diagnosis code for depression to the office or other outpatient E/M code.

Codes 96160 and 96161 are reported with 1 unit for each standardized instrument administered. Payer edits may limit the number of times 96160 and 96161 may be reported for an individual patient and/or on the same date of service. MUEs are set to 3 units for 96160 and 1 unit for 96161 per claim line. Append modifier 59 to the code for additional units on a second claim line.

Code 96160 is reported for administration of a patient-focused health risk assessment with scoring and documentation. This is differentiated from 96161 , which is used to report a health risk assessment focused on a caregiver for the benefit of the patient (eg, maternal depression screening).

Code 96160 cannot be used in conjunction with assessment and brief intervention for alcohol/substance abuse ( 99408 , 99409 ).

Check individual payer guidance to determine if and for what purposes 96160 is included as a covered and payable service under the payer’s policies (eg, some Medicaid plans pay for adolescent health questionnaires reported with 96160 ).

Code 96161 is reported for administration and scoring of a health risk assessment to a patient’s caregiver. Examples are a postpartum depression inventory administered to the mother of a newborn and administration of a standardized caregiver strain instrument to parents of a child who is seriously injured or ill.

Screening for postpartum depression is caregiver focused (sign/symptoms of depression in mother) but performed in this setting for the benefit of the infant. This service is reported as a service provided to the infant with 96161 and the appropriate ICD-10-CM code for the infant’s routine child health examination (eg, Z00.129 ).

Never report ICD-10-CM code Z13.32 (encounter for maternal depression screen) or Z13.31 (screening for depression) on the baby’s medical record/bill.

Check payer policy on adoption of 96161 versus a requirement to report as a service to the mother (ie, to mother’s health plan) with 96127 (brief emotional/behavioral assessment [eg, depression inventory, attention-deficit/hyperactivity disorder scale], with scoring and documentation, per standardized instrument). Many Medicaid plans provide separate payment for maternal depression screening at well-child visits, but specific reporting instructions may apply. Vaccines and administration services would also be reported.

Prevent denials! NCCI edits bundle 96160 and 96161 with 96110 and with IA ( 90460–90474 ) services, but a modifier is allowed when each code represents a distinct service and is clinically appropriate. Append modifier 59 (distinct procedure) to the bundled code (second column of NCCI edits) when these services are reported on the same date to a payer that has adopted NCCI edits.

➤ As part of a health supervision visit for a 9-month-old established patient, the physician directs clinical staff to administer a screening for postpartum depression that was not performed at the infant’s 6-month visit . After the mother has completed the screening instrument, clinical staff score and document the result in the patient record. The mother is also asked to complete a developmental screening instrument, which is scored and documented. The physician completes the preventive medicine service with no abnormal findings and counsels the patient’s mother about influenza immunization. With the mother’s consent, clinical staff administer 0.25 mL of a preservative-free split-virus vaccine. Anticipatory guidance that advises the mother that her screening indicates no current signs of postpartum depression is included, along with a list of symptoms that should prompt a call to her physician. The patient is scheduled to return for a second dose of influenza vaccine in 1 month. ICD-10-CM .  CPT .  Z00.129 (encounter for routine child health examination without abnormal findings) Z13.42 (screening for delayed milestones) Z23 (encounter for immunization)  99393 25 (preventive medicine visit) 96110 59 (developmental screening) 96161 59 (administration of caregiver-focused health risk assessment [eg, depression inventory] for the benefit of the patient, with scoring and documentation, per standardized instrument) 90460 (IA with physician counseling) 90685 (IIV4 vaccine, split virus, preservative free, 0.25 ml dose for IM use)  View Large Teaching Point: NCCI edits bundle codes 99393 and 9046 0 , 96110 and 96161 , and 96161 and 90460 . For each of the bundled code pairs, a modifier is allowed to override the edit when both services are provided and clinically appropriate. Electronic claim scrubbers are useful for identifying and addressing NCCI edit pairs before claim submission. Refer to Chapter 2 for more on NCCI edits.

Topical fluoride application by primary care physicians is a recommended preventive service for children from birth through 5 years of age (Grade B rating by the USPSTF). This service may be covered when provided alone or in conjunction with other services. Coverage is usually limited to once every 6 months.

ICD-10-CM code Z29.3 is reported to identify an encounter for prophylactic fluoride administration. When applicable, diagnosis of dental caries may be reported as a secondary diagnosis with codes in category K02 . Encounter for prophylactic fluoride administration is reported separately from the encounter for routine child health examination ( Z00.121 or Z00.129 ) when both services are provided at the same encounter.

➤ A 4-year-old established patient undergoes a routine preventive medicine service without abnormal findings. In addition, a medical assistant who has been qualified by a required online training and assessment program applies fluoride varnish to the child’s teeth under supervision of the pediatrician, who remains in the office suite. The pediatrician reports diagnosis code Z00.129 (routine child health examination without abnormal findings) linked to 99392 (established patient routine child health examination, age 1–4) and diagnosis code Z29.3 linked to 99188 (application of fluoride varnish). Teaching Point: Although 99188 specifies application by a physician or QHP, payers may allow billing of services by trained clinical staff under direct physician supervision (incident to). Some Medicaid plans require training of clinical staff through specific programs and documentation of training and/or certification. It is important to identify the requirements of individual payers before providing this service and maintain documentation demonstrating that all coverage requirements were met.

Report 0792T (application of silver diamine fluoride 38%, by a physician or QHP) when silver diamine fluoride is applied to cavity lesions. Refer to individual payer policies to verify coverage and requirements for payment for this service.

Some payers will provide coverage for oral evaluation and health risk assessment or other dental preventive services when provided on the same day as a preventive medicine visit; other payers will allow services only when they are provided at an encounter separate from a preventive medicine visit. It is important to know payer requirements for reporting.

Preventive counseling for oral health may be included as part of the preventive medicine service ( 99381–99395 ) or, if performed at a separate encounter, reported under the individual preventive medicine counseling service codes ( 99401–99404 ) or with an office or outpatient E/M service code ( 99202–99215 ). ICD-10-CM code Z13.84 may be reported for an encounter for screening for dental disorders.

Code on Dental Procedures and Nomenclature ( CDT ) codes also exist for topical application of fluoride varnish and fluoride. In addition, CDT codes exist for nutrition counseling to prevent dental disease, oral hygiene instruction, and oral evaluations. But acceptance of these codes by health plans may be limited to Medicaid plans.

For those carriers (particularly Medicaid plans under Early and Periodic Screening, Diagnostic, and Treatment) that cover oral health care, some will require a modifier. These modifiers are payer specific and should be used only as directed by your Medicaid agency or other private payer.

Learn more about coding for services that support a child’s oral health in the May 2023 AAP Pediatric Coding Newsletter article “Connecting Coding and Clinical Reports: Oral Health Care” ( https://doi.org/10.1542/pcco_book229_document001 ).

A test performed in the office laboratory should be billed with the appropriate laboratory code and, if performed, the appropriate blood collection code ( 36400–36416 ). Refer to the Blood Sampling for Diagnostic Study section in Chapter 12 .

Laboratories and physician offices performing waived tests may need to append modifier QW to the CPT code for Clinical Laboratory Improvement Amendments (CLIA)–waived procedures. The use of modifier QW is payer specific. To determine if a test is a CLIA-waived procedure, go to www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCLIA/search.cfm .

ICD-10-CM allows separate reporting of special screening examinations (codes in categories Z11–Z13 ) in addition to the codes for routine child health examinations when these codes provide additional information. A screening code is not necessary if the screening is inherent to a routine examination. Payer guidelines for reporting screening examinations may vary. When specific ICD-10-CM codes are required to support payment for a screening service, be sure to link the appropriate ICD-10-CM code to the claim line for the screening service.

A positive finding on a screening test does not change the test to a diagnostic test. When a screening test results in an abnormal finding that has been identified at the time of code assignment, list first the code for the screening or preventive service followed by a code for the abnormal finding. Failure to list the screening code first may affect the patient’s out-of-pocket costs for preventive services. Refer to Chapter 12 for information on coding for diagnostic tests in non-facility settings.

To meet the HEDIS measure for percentage of children who turned 2 years of age in a measurement year and who had one or more capillary or venous lead blood test(s) for lead poisoning by their second birthday, a laboratory report of lead screening test result, or a note indicating the date the test was performed and the result or finding, must be documented. Refer to Chapter 3 for more information on HEDIS measures.

Follow payer instructions for reporting that patients were referred to an outside laboratory for lead screening (eg, report a code for the appropriate lead screening test with modifier 90 , reference [outside] laboratory, and no charge).

A table of common pediatric screening laboratory tests and codes is included at www.aap.org/cfp2024 (“Screening Laboratory Tests and Codes”).

Codes 99401–99404 , 99411 , and 99412 are used to report risk factor reduction services provided for the purposes of promoting health and preventing illness or injury in people without a specific illness.

Preventive medicine service codes ( 99381–99395 ) include counseling, anticipatory guidance, and/or risk factor reduction interventions that are provided at the time of the periodic comprehensive preventive medicine examination. CPT states to “refer to codes 99401–99404 , and 99411–99412 for reporting those counseling/anticipatory guidance/risk-factor reduction interventions that are provided at an encounter separate from the preventive medicine examination.” Therefore, according to CPT , do not report 99401–99404 or 99411 or 99412 in addition to 99381–99397 .

Risk factor reduction services will vary with age and address issues such as diet, exercise, sexual activity, dental health, immunization safety counseling, injury prevention, safe travel, and family problems.

Services are reported according to time, and time should be distinctly documented (eg, 15 minutes spent in counseling about diet and exercise to reduce risk for diabetes).

Counseling, anticipatory guidance, and risk factor reduction interventions provided at the time of an initial or periodic comprehensive preventive medicine examination are components of the periodic service and not separately reported.

Risk factor reduction may be reported separately with other E/M services.

— E/M services (other than preventive medicine E/M services) reported on the same day must be separate and distinct.

— Time spent in the provision of risk factor reduction may not be used as a basis for the selection of the other E/M code.

When reporting a distinct E/M service, append modifier 25 to the code for the distinct E/M service.

Payment policies for preventive medicine counseling may vary by health plan. Ideally, recommended preventive medicine counseling provided outside a preventive E/M service ( 99381–99385 , 99391–99395 ) is a covered preventive service paid with no out-of-pocket cost to the patient/caregiver. It is important to know if a payer considers preventive medicine counseling bundled to a problem-oriented E/M service when provided on the same date of service. Plans may require that the preventive counseling be included in the level of problem-oriented E/M service reported in lieu of reporting the appropriate preventive counseling code. Written copies of payment policies should be documented to support billing for preventive medicine counseling as part of a problem-oriented E/M service instead of separately reporting as directed by CPT.

Codes 99401–99404 are time-based codes. Refer to Table 8-2 for code descriptors, required time, and RVUs for these services.

Abbreviation: RVU, relative value unit.

2023 RVUs, not geographically adjusted.

Report codes 99401–99404

According to a physician’s or other QHP’s face-to-face time spent providing counseling

For a new or an established patient

When the medical record includes documentation of the total counseling time and a summary of the issues discussed

Time for codes 99401–99404 is met when the midpoint is passed (eg, 8 minutes of service required to report a 15-minute service).

Codes 99401–99404 may be reported when expectant parents request a consultation with a pediatric physician regarding risk reduction for the fetus. But consultation or office and other outpatient E/M services are reported when the service is requested by another physician, another QHP, or an appropriate source (eg, genetic counselor). Refer to the Consultations section in Chapter 16 for information on reporting ICD-10-CM and CPT codes for expectant parent consultation services to the mother’s health insurance.

➤ A 7-week-old girl (established patient) is presented to a pediatrician with a scaly rash on her scalp . The infant is examined and found to have seborrheic infantile dermatitis of the scalp and skinfolds on the extremities. The pediatrician provides information on home management and risk of yeast infection and takes the opportunity to again counsel the mother about the need for immunization against hepatitis B, which the mother has previously refused. The indications, safety, and risks are discussed for 10 minutes and the mother agrees to revisit the issue with her husband, who has been strongly opposed in the past. The pediatrician documents the separate time and context of the counseling. ICD-10-CM .  CPT .  L21.0 (seborrheic infantile dermatitis)  99212 25 (MDM: 1 self-limited problem; assessment requiring an independent historian; and minimal risk of morbidity from treatment)  Z28.3 (under-immunization status) Z28.82 (immunization not carried out because of caregiver refusal)  99401   View Large Teaching Point: The pediatrician’s time of 10 minutes spent in preventive counseling supports reporting 99401 because the midpoint was passed (8 minutes are required for reporting a code assigned 15 minutes). Distinct documentation of the time and work of the preventive counseling is important to support payment for both services provided.

Risk factor reduction services provided to a group are reported according to time. The CPT midpoint rule for time applies (ie, time is met when the midpoint between the 2 codes is passed), as shown in Table 8-3 .

Refer to 99078 for reporting physician counseling to groups of patients with symptoms or an established illness. This service is reported for each participating child.

➤ A group of 10 patients aged 14 to 16 years attend a 50-minute session in the physician’s office to discuss contraception and sex-related health risks. The physician conducts the session. The session includes a 10-minute break that is not included in the time of service. Services are documented in each patient’s medical record and are reported for each child. ICD-10-CM .  CPT .  Z30.09 (encounter for other general counseling and advice on contraception)  99412 (risk-factor reduction counseling, group, 60 minutes)  View Large Teaching Point: Although 10 minutes of break time is not included in the time of the counseling service, code 99412 is supported because the midpoint between the 30 minutes assigned to 99411 and the 60 minutes assigned to 99412 is passed. Services provided to a group of patients may not be reported as individual office E/M visits ( 99202– 99215 ) except as specifically designated in payer policy and may be limited to time spent counseling each patient individually.

Behavior change interventions are for people who have a behavior that is often considered an illness, such as tobacco use and addiction or substance use or misuse. Behavior change services may be reported when performed as part of the treatment of conditions related to or potentially exacerbated by the behavior or when performed to change the harmful behavior that has not yet resulted in illness. Table 8-4 shows the codes and RVUs assigned to behavior change intervention codes.

Behavior change interventions involve validated interventions, shown in Figure 8-2 .

Figure 8-2. Behavior Change Interventions

● Behavior change intervention codes 99406–99409 are reported when

— Services are provided by a physician or QHP for patients who have a behavior that is often considered an illness (eg, tobacco use and addiction, substance use or misuse).

— Services involve specific validated interventions, including assessing readiness for and barriers to change, advising change in behavior, providing specific suggested actions and motivational counseling, and arranging for services and follow-up care.

● Codes 99406–99409 include specific time requirements that must be met (eg, at least 15 minutes must be spent in counseling to support reporting of code 99408 ). The CPT midpoint rule does not apply to codes 99406–99409 .

✖ Do not separately report code 96160 for screening instruments used in conjunction with codes 99408 and 99409 .

● Medical record documentation supports the total time spent in the performance of the service, and a detail of the behavior change intervention is provided.

Behavior change intervention services cannot be performed on a parent or guardian of a patient and reported under the patient’s name.

Behavior change interventions may be reported separately with preventive medicine or other E/M services.

— E/M services reported on the same day must be separate and distinct.

— Time spent in the provision of behavior change intervention may not be used as a basis for the selection of the other E/M code.

When reporting a distinct E/M service, append modifier 25 to the code for the distinct E/M service (eg, 99213 25 ).

Refer to the Physician Group Education Services section in Chapter 12 for an example of how 99078 is used.

➤ During an office visit for a 17-year-old new patient for an unrelated problem, it is learned that he has been smoking for 2 years but would like to quit. The physician spends 15 minutes discussing specific methods to overcome barriers, pharmacological options, behavioral techniques, and nicotine replacement. The patient is referred to a community support group and a follow-up visit is scheduled in 2 weeks to provide additional encouragement and counseling as needed. Diagnosis is tobacco use. ICD-10-CM .  CPT .  Use the code appropriate for the problem addressed.  99202–99205 25 (based on service performed and documented)  Z72.0 (tobacco use) Z71.6 (tobacco abuse counseling)  99407   View Large Teaching Point: If only general advice and encouragement to stop smoking had been provided, it would have been considered part of the new patient office visit. Counseling time must be documented. ICD-10-CM does not include a code for use of vaping products without a diagnosis of abuse or a vaping-related illness. Report Z71.89 (other specified counseling) when counseling is focused on risks associated with vaping. Refer to F17.29- for codes for nicotine dependence and vaping.
➤ A 14-year-old established patient with primarily hyperactive attention-deficit/hyperactivity disorder (ADHD) presents for a preventive E/M service. The patient and parents report no problems in school and no concerns with current ADHD management. During time alone with the patient, the physician uses a structured screening tool to interview the patient about substance use. The result is positive, and the physician spends a total of 20 minutes interviewing the patient about substance use history and counseling the patient about risks associated with alcohol and drug use, not driving or riding with someone under the influence, and seeking an agreement to avoid future use. ICD-10-CM .  CPT .  Z00.129 (routine child health examination without abnormal findings) F90.1 (ADHD, predominantly hyperactive type)  99394 25 (preventive medicine visit)  Z71.89 (other specified counseling)  99408   View Large Time of counseling should be specifically documented as beginning after conclusion of the preventive medicine service.

ICD-10-CM guidelines state that substance use codes (eg, F10.99 , alcohol use, unspecified with unspecified alcohol-induced disorder) should be assigned only when the use is associated with a mental or behavioral disorder and such a relationship is documented by the provider.

Learn more about reporting behavior change interventions in the June 2023 AAP Pediatric Coding Newsletter article “Connecting Coding and Policy: Getting Paid for Tobacco and Substance Use Screening and Intervention” ( https://doi.org/10.1542/pcco_book230_document001 ).

Modifier 33 is used to differentiate services provided as recommended preventive care when the service might also be provided for diagnostic indications. Some payers provide a listing of services for which modifier 33 is required when provided as a preventive service.

The appropriate use of modifier 33 will reduce claim adjustments related to preventive services and corresponding payments to members.

Modifier 33 should be appended only to codes represented in one or more of the following categories:

— Services rated A or B by the USPSTF

— Immunizations for routine use in children, adolescents, and adults as recommended by ACIP

— Preventive care and screenings for children as recommended by Bright Futures (AAP) and newborn testing (American College of Medical Genetics and Genomics)

— Preventive care and screenings provided for women supported by HRSA

The USPSTF grades A and B are defined as follows:

Grade A: The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

Grade B: The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Most health plans cover preventive services with grade A or B without cost to the patient (ie, no deductible, co-payment, or coinsurance).

● DO NOT USE MODIFIER 33

✖ When the CPT code(s) is identified as inherently preventive (eg, preventive medicine counseling)

✖ When the service(s) is not indicated in the categories noted previously

✖ With an insurance plan that continues to implement the cost-sharing policy on preventive medicine services (legacy health plan)

● Check with your payers before fully implementing the use of modifier 33 to verify any variations in reporting requirements. Modifier 33   is not used for benefit determination by some payers and may be required by others only for services that may be either diagnostic/therapeutic or preventive.

➤ A 12-year-old established patient is seen for behavioral intervention for obesity to address excess calorie intake and family history of type 2 diabetes. The patient and her parents previously received counseling on the health risks associated with obesity and requested assistance with lifestyle changes to help the patient recover and maintain a healthy weight. The physician uses shared decision-making to develop a plan for adopting a healthier lifestyle that will lead to weight loss and improve the health status of the patient. The physician’s total time on the date of service is 35 minutes. ICD-10-CM .  CPT .  E66.9 (obesity, unspecified) Z68.54 (BMI ≥95th percentile) Z83.3 (family history of diabetes mellitus)  99214 33 (level 4 established patient office visit, total time 30–39 minutes)  View Large Teaching Point: Modifier 33 is appended to 99214 to indicate the preventive nature of the service, based on the USPSTF Grade B recommendation that clinicians screen for obesity in children and adolescents 6 years and older and offer to provide or refer them for comprehensive, intensive behavioral interventions to promote improvements in weight status.

Code 99429 may be reported if these options are not suitable. If the unlisted code is used, most payers will require a copy of the progress notes filed with the claim.

When a problem or an abnormality is addressed, requires significant additional work (eg, symptomatic atopic dermatitis, exercise-induced asthma, migraine headache, scoliosis), and is medically necessary, it may be reported with the office or other outpatient services codes ( 99202–99205 , 99212–99215 , and modifier 25 ) in addition to the preventive medicine services code.

Some payers have adopted a policy that problem-oriented E/M services provided on the same date as a preventive medicine E/M service be paid at 50% of the contractual amount agreed on under the health plan contract. When reporting to these payers, be sure to include all work related to the problem-oriented encounter in determining the level of service provided. Physicians should not reduce the level of service reported.

The presence of a chronic condition(s) in and of itself neither changes a preventive medicine visit to a problem-oriented visit nor unilaterally supports a separate problem-oriented E/M service ( 99202–99205 , 99212–99215 ) with the well visit, unless it has been separately addressed with a significant problem-oriented service.

An insignificant problem or condition (eg, minor diaper rash, stable chronic problem not evaluated at this visit, renewal of prescription medications without reevaluation) that does not require significant MDM or time cannot be reported as a separate E/M service.

Although a separate E/M service is not reported when a minor problem or chronic condition requires less than significant additional work, the diagnosis code for the problem or chronic condition may be reported in addition to Z00.121–Z00.129 (routine child health examination).

It is important to make parents aware of any additional charges that may occur at the preventive medicine encounter. This includes, but is not limited to, a significant, separately identifiable E/M service.

— Some patients will be required to provide a co-payment for the non–preventive medicine visit code under the terms of their plan benefit even when there is no co-payment required for the preventive medicine visit. Legally, this co-payment cannot routinely be written off.

When reporting both E/M services,

The documentation of the problem-oriented service must be distinct from that of the preventive service (even if included in the same encounter note) and clearly support the level of service reported.

When the level of service for the problem-oriented E/M service is selected according to the physician’s total time on the date of the encounter, the physician’s total time (not including any time spent providing and documenting the preventive service) spent addressing the problem must be distinctly documented in addition to documentation of the problem workup (eg, history of present illness, examination, records or test results reviewed), assessment, and plan. The total time of the problem-oriented E/M service does not include any time spent providing and documenting the preventive service.

Documentation might indicate, “My total time of XX minutes was directed to activities of evaluating and managing X condition after I provided the preventive service.”

Modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) should be appended to the problem-oriented service code (eg, 99212 25 ). If vaccines are given at the same encounter, append modifier 25 to the problem-oriented E/M service code and to the preventive medicine service code to prevent payer bundling edits that may allow payment only for IA.

ICD-10-CM well-care diagnosis codes (for the code list, refer to the ICD-10-CM Codes for Preventive Care Visits section earlier in this chapter) should be linked to the appropriate preventive medicine service code ( 99381–99395 ) and the code for problems or findings addressed that is linked to the problem-oriented service code ( 99202–99205 , 99212–99215 ).

➤ A 10-year-old boy receives health supervision at a well-child visit . This established patient also has previously diagnosed gastroesophageal reflux disease (GERD). The patient notes an increase in symptoms and asks about a change in medication. After providing the preventive E/M service, the physician reevaluates the child’s symptoms of GERD, medication adherence, and eating habits. A new medication is prescribed. ICD-10-CM .  CPT .  Z00.121 (well-child check with abnormal findings) K21.9 (gastro-esophageal reflux disease without esophagitis)  99393 (preventive medicine visit)  K21.9 (gastro-esophageal reflux disease without esophagitis)  99214 25 (office E/M service, moderate level MDM)  View Large Teaching Point: Documentation should clearly support the separate EM of the GERD, discussion topics, and plan of care for the problem.
➤ A 10-year-old boy with previously diagnosed GERD is seen for a preventive medicine visit. The patient reports improvement since medication was started and his mother requests a refill of the prescription. There are no new abnormal findings at the encounter. An order for the medication refill is placed in addition to provision of the preventive E/M service. ICD-10-CM .  CPT .  Z00.129 (well-child check without abnormal findings) K21.9 (gastro-esophageal reflux disease without esophagitis)  99393   View Large Teaching Point: Because there was no reevaluation of the GERD at the encounter, only the preventive E/M code is reported. The diagnosis code for GERD may be reported as an additional diagnosis to the code for the well-child checkup but is not a finding of the well-child checkup because the condition was not new or exacerbated.

Refer to the “Preventive and Problem-Oriented Services: Coding Continuum” box later in this chapter for additional examples of coding for problems addressed at a preventive encounter.

For another example of an encounter at which both preventive and problem-oriented E/M services are provided and the opportunity to try to correctly assign procedure and diagnosis codes, refer to the June 2023 AAP Coding Newsletter article “You Code It! Combined Preventive and Problem-Oriented Encounter” ( https://doi.org/10.1542/pcco_book230_document002 ) and compare your answers to those in the related article, “You Code It! Answers: Combined Preventive and Problem-Oriented Encounter” ( https://doi.org/10.1542/pcco_book230_document006 ).

To test your knowledge of coding for preventive services, complete the quiz found at the end of this chapter, after the continuum and resources. Answers to each quiz are found in Appendix III .

Abbreviations: CPT, Current Procedural Terminology; E/M, evaluation and management; MDM, medical decision-making; QHP, qualified health care professional; SSRI, selective serotonin reuptake inhibitor.

Time-based E/M: Time is the total time spent in activities related to the problem-oriented E/M service by the physician or QHP on the date of the encounter. Do not include time of the preventive medicine service or time of other separately reported services.

In some cases, a problem that requires higher levels of E/M service (ie, 99214 or 99215 ) may warrant delay of the preventive E/M service.

In this chapter, common pediatric preventive services and reporting for a combination of preventive and problem-oriented services were discussed. Following are takeaways from this chapter:

Well-child or preventive medicine services are a type of E/M service and are reported with codes 99381–99395 .

Appropriate diagnosis coding for preventive medicine is based on the patient’s age and, for infants and children, on whether an abnormality is identified during the service.

Vaccine services are reported with 2 families of CPT codes: one for the vaccine serum (the product) and one for the services associated with the administration of the vaccine.

Codes 99401–99404 , 99411 , and 99412 are used to report risk factor reduction services provided for the purposes of promoting health and preventing illness or injury in people without a specific illness. Codes 99406–99408 are reported for behavior change intervention services.

An insignificant problem or condition that does not require significant MDM or time cannot be reported as a separate E/M service.

“7 Rights of Vaccine Administration” ( www.aap.org/en/patient-care/immunizations/implementing-immunization-administration-in-your-practice/vaccine-administration )

AAP Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents , 4th Edition ( www.aap.org/en/practice-management/bright-futures )

AAP/Bright Futures periodicity schedule, “Recommendations for Preventive Pediatric Health Care” (refer also to the insert) ( www.aap.org/en/practice-management/care-delivery-approaches/periodicity-schedule )

AAP “COVID-19 Vaccine Administration: Getting Paid” ( https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/covid-19-vaccine-for-children/covid-19-vaccine-administration-getting-paid )

AAP “Refusal to Vaccinate,” including a vaccine refusal form in English and in Spanish ( www.aap.org/en/patient-care/immunizations/implementing-immunization-administration-in-your-practice/refusal-to-vaccinate )

AAP “Payment for Oral Health Services” ( www.aap.org/en/patient-care/oral-health/payment-for-oral-health-services )

AAP Pediatric Vaccines: Coding Quick Reference Card 2024 ( https://shop.aap.org/pediatric-vaccines-coding-quick-reference-card-2024 )

AAP Section on Ophthalmology and Committee on Practice and Ambulatory Medicine, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists “Instrument-Based Pediatric Vision Screening Policy Statement,” Pediatrics ( https://doi.org/10.1542/peds.2012-2548 )

“Vaccine Financing and Coding” ( www.aap.org/en/practice-management/practice-financing/coding-and-valuation/vaccine-financing-and-coding )

“Coding and Billing Basics: Ruling Out Misinformation,” July 2022 ( https://doi.org/10.1542/pcco_book219_document005 )

“Coding for Vaccines Not Administered,” July 2020 ( https://doi.org/10.1542/pcco_book195_document007 )

“Connecting Coding and Clinical Reports: Oral Health Care,” May 2023 ( https://doi.org/10.1542/pcco_book229_document001 )

“Connecting Coding and Policy: Getting Paid for Tobacco and Substance Use Screening and Intervention,” June 2023 ( https://doi.org/10.1542/pcco_book230_document001 )

“You Code It! Combined Preventive and Problem-Oriented Encounter” and “You Code It! Answers: Combined Preventive and Problem-Oriented Encounter,” June 2023 ( https://doi.org/10.1542/pcco_book230_document002 and https://doi.org/10.1542/pcco_book230_document006 )

AMA Category I vaccine codes ( www.ama-assn.org/practice-management/cpt/category-i-vaccine-codes )

Appendix II

CDC VFC program ( www.cdc.gov/vaccines/programs/vfc/index.html )

FDA CLIA test category database ( www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCLIA/search.cfm )

FDA National Drug Code Directory ( www.fda.gov/drugs/drug-approvals-and-databases/national-drug-code-directory )

“FAQ: Immunization Administration”

“Preventive Medicine Encounters: What’s Included? (Letter Template)”

“Screening Laboratory Tests and Codes”

Agency for Healthcare Research and Quality, US Department of Health and Human Services, National Guideline Clearinghouse ( www.qualitymeasures.ahrq.gov )

CPT Category II codes ( www.ama-assn.org/practice-management/cpt-category-ii-codes )

VFC eligibility criteria ( www.cdc.gov/vaccines/programs/vfc/providers/eligibility.html )

Which criteria are used in CPT code selection for a preventive E/M service?

The child’s gender and age

The child’s age on their next birthday

The child’s age on the date of the encounter and whether the child is a new or established patient

Whether the child’s encounter included abnormal findings or no abnormal findings

Which service is reported with Z00.121 (routine child health examination with abnormal findings)?

Routine examination for a child with increased asthma symptoms that require a change in management

Routine examination of a child with resolving otitis media diagnosed at an earlier encounter

Routine examination of a child with stable asthma

Routine examination of a child with a known benign cardiac murmur

Which code is reported for scoring and documentation of a standardized instrument completed to screen for autism?

Which codes are reported to an infant’s health plan for screening for maternal depression?

96161 and Z13.32 (maternal depression screen)

96161 and Z13.31 (screening for depression)

96127 and Z00.1- (routine newborn or child health exam)

96161 and Z00.1- (routine newborn or child health exam)

True or false? An office E/M code (eg, 99213 ) is always reported when a prescription drug refill is ordered during a preventive E/M service.

● indicates a new code; ▲ , revised; # , re-sequenced; ➕ , add-on; ★ , audiovisual technology; and 🔈 , synchronous interactive audio.

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well child visit billing code

Pediatric Preventive Services: Coding Quick Reference Card 2024

AAP Committee on Coding and Nomenclature (COCN)

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Description

This convenient card features all evaluation and management service codes, as well as other recommended service codes, for well-child visits from birth to 21 years of age.

This 11″ × 11.5″ card is fully updated for 2024 and laminated for extra durability.

  • ISBN-13: 978-1-61002-694-9
  • Product Code: MA1118
  • Publication Date: November 1, 2023
  • Format: Forms and Charts
  • Trim Size: 11 inches x 8.5 inches
  • Publisher: American Academy of Pediatrics
  • Availability: On Backorder

well child visit billing code

American Academy of Pediatrics Committee on Coding and Nomenclature (COCN)

The AAP Committee on Coding and Nomenclature (COCN) is responsible for reviewing of all proposed changes to Current Procedural Terminology (CPT) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding structures to determine whether the Academy will endorse the proposal; participates in the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) survey process by validating clinical vignettes, evaluating survey data and deciding on physician work and practice expense relative value units (RVUs) to recommend to the RUC; and serves as a review panel regarding other activities such as identifying Academy positions on the Medicare Resource-Based Relative Value Scale (RBRVS). 

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Medical Billing and Coding - Procedure code, ICD CODE.

CPT CODE 99381, 99382 – 99385 – Preventive visit new patient

Sep 25, 2016 | Medical billing basics

CPT Code and description

99381 – Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)

99382 – Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years)

99383 – Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) – Average fee amount $110 – $130

99384 – Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) Average fee amount $120 – $140

99385 – Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years  –  Average fee amount – $120 – $ 150

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397 , Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse  Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

When a Preventive Medicine service and Other E/M services are provided during the same visit, only the Preventive Medicine service will be reimbursed.

Screening services include cervical cancer screening; pelvic and breast examination; prostate cancer screening/digital rectal examination; and obtaining, preparing and conveyance of a Papanicolaou smear to the laboratory. These Screening procedures are included in (and are not separately reimbursed from) the Preventive Medicine service rendered on the same day.

Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes.

Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes.

Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes.

Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services.

For a list of specific codes that are included in (and not separately reimbursed from) Preventive Medicine Services see the Applicable Codes section below.

For the purposes of this policy, Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional is defined as a physician, hospital, ambulatory surgical center, and/or other health care professional of the same group and Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional reporting the same Federal Tax Identification number.

PREVENTIVE MEDICINE SERVICES, NEW PATIENT

Initial comprehensive preventive medicine evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures for a new patient.

Code Description

99381 Infant (age under 1 year) 99382 Early childhood (ages 1 through 4 years) 99383 Late childhood (ages 5 through 11 years) 99384 Adolescent (ages 12 through 17 years) 99385 18–39 years 99386 40–64 years 99387 65 years and over

PREVENTIVE MEDICINE SERVICES, ESTABLISHED PATIENT

Periodic comprehensive preventive medicine re-evaluation and management of an individual, including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures for an established patient.

Code Description 99391 Infant (age under 1 year) 99392 Early childhood (ages 1 through 4 years) 99393 Late childhood (ages 5 through 11 years) 99394 Adolescent (ages 12 through 17 years) 99395 18–39 years 99396 40–64 years 99397 65 years and over

New versus Established client: A new client is defined as one who has not received any professional services from a physician/qualified health care professional in your health department, within the last three years, for a billable visit that includes some level of evaluation and management (E/M) service coded as a preventive service using 99381-99387 or 99391-99397, or as an evaluation & management service using 99201-99205 and 99211-99215. If the client’s only visit to the Health Department is WIC or immunizations without one of the above service codes, it does not affect the designation of the client as a new client; the client can still be NEW. Remember that a client may be new to a program but established to the health department if they have received any  professional services from a physician/qualified health care professional.

In this case, you would use the forms for a “new” patient for that program even though the client is billed as “established” to the health department. Due to National Correct Coding Initiative (NCCI) edits the practice of billing a 99211, and then later billing a new visit code, has been eliminated. Many LHDs have been billing a 99211 (usually an RN only visit) the first time they see a patient and then, up to 3 years later, bills a 99201 – 99205 or 99381-99387 (New Visit). Examples may include: billing the 99211 for pregnancy test counseling or head lice check by RN and then a new visit when the patient comes in for their first prenatal, Family Planning or Child Health visit. Now that the NCCI edits have been implemented, all of those “new” visits will deny because the LHD will have told the system (via billing a 99211) that the patient is “established.” Consult your PHNPDU Nursing Consultant if you have questions.

ADULT PREVENTIVE CARE PROCEDURE CODES

Code Description 76091 Mammogram (specialty center) 82270 Fecal Occult Blood Test (lab procedure code only) 82465 Total Serum Cholesterol (lab procedure code only) 84153 PSA (lab procedure code only) 86580 Tuberculosis (TB) Screening (PPD) 88150 Pap Smear (lab procedure code only) 90658 Flu Shot 90718 Td-Diphtheria–Tetanus Toxoid–0.5 ml 90732 Pneumovax

REIMBURSEMENT GUIDELINES Preventive Medicine Service and Problem Oriented E/M Service

A Preventive Medicine CPT or HCPCS code and a Problem-Oriented E/M CPT code may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. If the E/M code represents a significant, separately identifiable service and is submitted with modifier 25 appended, Oxford will reimburse the Preventive Medicine code plus 50% of the Problem-Oriented E/M code. Oxford will not reimburse a Problem-Oriented E/M code that does not represent a significant, separately identifiable service and that is not submitted with modifier 25 appended.

Preventive Medicine Service and Other E/M Service

A Preventive Medicine CPT or HCPCS code and Other E/M CPT or HCPCS codes may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. However, Oxford will only reimburse the Preventive Medicine CPT or HCPCS code.

QUESTIONS AND ANSWERS 1 Q: Why does Oxford reduce reimbursement to 50% for an evaluation and management (E/M) service (99201-99205 or 99212-99215 with modifier 25) billed for the same person on the same date of service as a Preventive Medicine service ?

A: Oxford recognizes that a visit may begin as a Preventive Medicine service, and in the process of the examination it may be determined that a disease related condition exists (evaluation and management). When this occurs, the level of decision-making during such a visit may be more complex than the decision-making during a Preventive Medicine visit. However, there are elements of the Preventive Medicine service (e.g., making the appointment, obtaining vital signs, maintaining and stocking the exam room, etc.) that are duplicated in the reimbursement for an E/M code; these duplicated practice expense services are 50% of the E/M cost.

2 Q: In what situation is CPT code 96110 reimbursable?

A: As defined, CPT code 96110 represents developmental screening with interpretation and report. In the introduction to the section in which this code appears, the CPT book states that “it is expected that the administration of these tests will generate material that will be formulated into a report.” Because a physician obtains developmental information as an intrinsic part of a preventive medicine service for an infant or child and because this information is sometimes obtained in the form of a questionnaire completed by the parents, it is expected that this code will be reported in addition to the preventive medicine visit only if the screening meets the code description. Physicians should report CPT code,  for developmental screening or other similar screening or testing, separate and distinct from the Preventive medicine service only when the testing or screening results in an interpretation and report by the physician being entered into the medical record.

3 Q: Why is Q0091 not separately reimbursable when billed with a Preventive Medicine code?

A: Oxford considers Q0091 (obtaining, preparing and conveying a cervical or vaginal smear to the laboratory) to be an integral part of a Preventive Health Care service. Therefore, this component of a Preventive visit is not separately reimbursable.

4 Q: Why is 99173 (screening test of visual acuity) not separately reimbursable when billed with a Preventive Medicine code?

A: Oxford considers vision screening using an eye chart to be integral to a Preventive Medicine examination in the same way that measurements of height, weight and blood pressure are integral to a Preventive Medicine examination. Therefore, vision screening using an eye chart is not reimbursed separately from a Preventive Medicine examination.

5 Q: Why is 99172 (visual function screening) not separately reimbursable when billed with a Preventive Medicine code?

A: The CPT Book clearly states that this service should not be reported in addition to an E/M code.

6 Q: How does Oxford reimburse for screening tests based on a questionnaire completed by the patient or a family member when done in conjunction with a Preventive Medicine service?

A: Counseling, anticipatory guidance and risk factor reduction interventions are integral to a Preventive Medicine visit. Historical information may be obtained either through direct questioning or through completion of a written questionnaire. The responses on a questionnaire often identify areas for more focused interventions or treatments. Since this screening is part of a Preventive Medicine service, it is not reimbursed separately. Occasionally, a screening instrument requires interpretation, scoring, and the development of a report separate from the Preventive Medicine encounter. In those  situations, where a CPT code exists for that service, screening, interpretation and development of a report is reimbursed separately from a Preventive Medicine service. State Exceptions

Arizona Per Arizona State Regulations, effective 4/1/14 claims for EPSDT services must be submitted on a CMS (formerly HCFA) 1500 form for members up to age 21. Providers must bill for preventative EPSDT services using the preventative service, office or other outpatient services and preventive medicine CPT codes (99381 – 99385, 99391 – 99395) with an EP modifier.

EPSDT visits are paid at a global rate for the services specified and no additional reimbursement is allowed. Providers must use an EP modifier to designate all services related to the EPSDT well child check-ups, including  routine vision and hearing screenings.

* A list of preventative, office or other outpatient services that are considered included in the global payment of the preventive medicine CPT code is attached to this policy

*  Ocular photoscreening with interpretation and report, bilateral (CPT code 99174) is allowed for members under age 19. Arizona EPSDT Bundled Codes Lis t

A list of preventative, office or other outpatient services that are considered included in the global payment for the preventive medicine CPT codes (99381 – 99385, 99391 – 99395).

DC EPSDT Well-Child Visit Billing Reference Guide

When conducting a well-child visit (WCV), a primary care provider (PCP) must perform all components required in a visit and all age-appropriate screenings and/or assessments as required in the DC Medicaid HealthCheck Periodicity Schedule. Covered screening services are medical, developmental/mental health, vision, hearing and dental. The components of medical screening include:

* Comprehensive health and developmental history that assesses for both physical and mental health as well as for substance use disorders

* Comprehensive, unclothed physical examination

* Appropriate immunizations (as established by ACIP)

* Laboratory testing (including blood lead screening appropriate for age and risk factors)

* Health education and anticipatory guidance for both the child and the caregiver.i

To bill for a well-child visit:

* Use the age-based CPT code (99381-99385; 99391-99395). See Table 1.

o Use the following ICD-9 diagnosis codes listed in Table 1 in conjunction with the CPT Code

* Bill for each separate assessment/screening performed using the applicable CPT code from Table 2.

* If a screening or assessment is positive and requires follow-up or a referral, please use modifier TS with the applicable screening code that had a positive result.

DO NOT USE THE E&M OUTPATIENT VISIT CODES (99201-99205; 99213-99215) TO BILL FOR A WELLCHILD VISIT.

Table1: Age Based Preventive Visit CPT Codes Table 2: Screening/Assessment CPT Codes Patient’s Age                CPT Code           Dx Code

< 1 year  99381/91  new/established  V20.31,  20.32,  V20.2

1 – 4 years 99382/92 V20.2

5 – 11 years 99383/93 V20.2

12 – 17 years 99384/94 V20.2

18 – 21 years 99385/95 V70.0

HCY/EPSDT Billing Codes [1][2][3] AGE CPT Code: New Patient AGE CPT Code:

Established Patient Modifiers As Applicable ICD-10-CM Diagnosis Codes Preventive visit, Modifier EP: Used with procedure codes 99381-99385 and 99391-99395 when a Full or Partial screening is performed.

Modifier 52: Used with modifier EP when all components have not been met, but at least the first 5 or more components were completed according to the HCY/EPSDT requirements.

Modifier 59: Used when only components related to developmental and mental health are screened.

Modifier 25: Used on the significant, separately identifiable problem-oriented evaluation and management service when it is provided on (1) the same day as the preventive medicine service and/or (2) with administration of immunizations. Please note that modifier 25 is not to be used on preventive codes and needs to be billed using office or outpatient codes (99201-99215), and that these screenings bundle administration of immunizations.*Documentation must support the use of a modifier 25. See MO HealthNet Provider Manual. Modifier UC: Used when a referral is made for further care.

Z00.110 Newborn under 8 days old

Z00.111 Newborns 8 to 28 days old or

Z00.121 Routine child health exam with abnormal findings

Z00.129 Routine child health exam without abnormal findings Preventive visit, 1-4

99382 Preventive visit, 1-4

99392 Z00.121 Z00.129 Preventive visit, 5-11

99383 Preventive visit, 5-11

99393 Z00.121 Z00.129 Preventive visit, 12-17

99384 Preventive visit, 12-17

99394 Z00.121 Z00.129 Preventive visit, 18 or older

99385 Preventive visit, 18 or older

99395 Z00.00 General adult medical exam without abnormal findings Z00.01 General adult medical exam with abnormal findings

NCCI Edit with preventive visits

National Correct Coding Initiative (NCCI) Impacts on Immunization and Evaluation & Management (E&M) Codes Effective April 1, 2014, the Department will no longer reimburse NCCI procedure-to-procedure (PTP)  edits when immunization administration procedure codes (CPT 90460-90474) are paired with preventative medicine E&M service procedure codes (CPT 99381-99397).

If a significant separately identifiable E&M service (e.g. new or established patient office or other outpatient services [99201-99215], office or other outpatient consultation [99241-99245], emergency department service [99281-99285], preventative medicine service [99381-99429] is performed), the appropriate E&M service code should be reported in addition to the vaccine and toxoid administration codes.

Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of “0” indicates that NCCI  PTP-associated modifiers cannot be used to bypass the edit. A modifier indicator of “1” indicates that NCCI PTP-associated modifiers may be used to bypass an editunder appropriate circumstances. A modifier indicator of “9” indicates that the edit has been deleted, and the modifier indicator is not relevant. The Correct Coding Modifier Indicator can be found in the files containing Medicaid NCCI PTP edits on the CMS website.

A modifier should not be added to a HCPCS/CPT code solely to bypass an NCCI PTP edit, if the clinical circumstances do not justify its use. If the E&M service is significant and separately identifiable and performed on the same day, the E&M code should be billed with the vaccine and toxoid administration codes using PTP associated modifier ‘25’. Modifier ‘25’ is only valid when appended to the E&M codes. Do not append to the immunization administration procedure codes 90460-90474.

Therapeutic Injections Office visits (CPT codes 99201-99205; 99212-99215; 99381-99397) will not be separately reimbursed when submitted with therapeutic injections (CPT code 96372). Please append Modifier 25 to the disallowed E/M code if a significant separately identifiable E/M service was performed. Note: CPT code 96372 has been valued to include the work and practice expenses of CPT code 99211. A modifier will not override this edit.

Visual Acuity Testing CPT code 99173, visual acuity screening test, is separately reimbursable when submitted with preventive office visits (CPT codes 99381-99397). Vital Capacity Vital capacity (CPT code 94150) is considered incidental to the overall service provided, whether an office visit or a procedure, and will not be separately reimbursed.

Payment guidelines

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling,  anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a  preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same  visit. When this occurs, Oxford will reimburse thePreventive Medicine service plus 50% the Problem-Oriented E/M  service code when that code is appended with modifier  25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes. Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes. Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes. Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services.

Reporting Evaluation and Management Services With Immunizations

E/M services most often reported with the vaccine product and immunization administration include new and established patient preventive medicine visits (CPT codes 99381–99395), problem-oriented visits ( CPT 99201 –99215), and preventive medicine counseling services (99401–99404). Any of the aforementioned E/M codes can be reported as a single service or in combination when performed and documented on the same day of service by the same physician or physician of the same group and specialty.

The E/M service must be medically indicated, significant, and separately identifiable from the immunization administration.

• Payers may require modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to be appended to the E/M code to distinguish it from the administration of the vaccine.

• CPT code 99211 (established patient E/M, minimal level, not requiring physician presence) should not  be reported when the patient encounter is for vaccination only because the Medicare Resource-BasedRelative Value Scale (RBRVS) relative values for the immunization administration codes incl de administrative and clinical services (ie, greeting the patient, routine  vital signs, obtaining a vaccine history, presenting the VIS and responding to routine vaccine questions, preparation and administration of the vaccine, and  documentation and observation of the patient following the administration of the vaccine). However, if the service is medically necessary, significant, and separately  identifiable, it may be reported with modifier 25 appended to the E/M code (99211). Note that the medical record must clearly state the reason for the visit, brief  history, physical examination, assessment and plan, and any other counseling or discussion items. The progress note must be signed with the physician’s  countersignature. For more information and clinical vignettes on the appropriate use of code 99211 during immunization administration, visit  www.aap.org/pubserv/codingforpeds for a copy of the AAP position paper on reporting 99211 with immunization administration. Payers who do not follow the Medicare RBRVS  may allow payment of code 99211 with immunization administration. Know your payer guidelines, and if payment is allowed, make certain that the guidelines are in  writing and maintained in your office. Be aware that a co-payment will be required when the “nurse” visit is reported.

• The same guidelines apply to physician visits (99201–99215). In other words, if a patient is seen for the administration of a vaccine only, it is not appropriate to report an E/M visit if it is not medically necessary, significant, and separately identifiable.

• If at the time of a preventive medicine visit a patient has a problem or abnormality that is addressed and requires significant additional work to perform the required key components, a problem-oriented E/M code (99201–99215) may be reported in addition to the preventive medicine services code. There should be separate documentation for the 2 services in the medical record. Typically the level of service is based on the level of history and medical decision-making that are performed and documented because the physical examination component is most often performed as part of the age-appropriate examination included in the preventive medicine service. Modifier 25 must be appended to the problemoriented E/M service to alert the payer that it was significant and separately identifiable. Each code is linked to the appropriate ICD-9-CM code.

CPT codes 99401–99404 (preventive medicine counseling, individual) are used for the purpose of promoting health and preventing illness or injury. They are not reported when counseling is related to a condition, disease, or treatment. These are time-based codes that require medical record documentation of the total time spent in counseling and a summary of the issues discussed. Codes 99401–99404 may be reported separately from other E/M services (eg, office visits, preventive medicine visits) when performed on the same day. Modifier 25 must be appended to codes 99401– 99404 to signify to the payer that the preventive medicine counseling was significant and separately identifiable from the preventive medicine or problem-oriented E/M visit.

• Remember that reviewing or discussing the risks and benefits of vaccines and addressing all other patient and parent concerns and questions related to vaccines and immunization administration are included in the immunization administration codes. However, if vaccine counseling is performed and the parent or patient refuses vaccines, the time spent in counseling may be separately reported. Also, if after additional time is spent in vaccine counseling, the parent or patient then decides to accept the immunizations and the time and effort exceeds that normally spent by the physician, it is still appropriate to report these codes in addition to the E/M visit and immunization administration. Make certain that the medical record supports the excess time and effort of counseling.

Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service

When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a noncovered preventive medicine service (CPT codes 99381- 99397), consider the covered visit to be provided in lieu of a part of the preventive

medicine service of equal value to the visit. A preventive medicine service (CPT codes 99381-99397) is a noncovered service. The physician may charge the beneficiary, as a charge for the noncovered remainder of the service, the amount by which the physician’s current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit. Pay for the covered visit based on the lesser of the fee schedule amount or the physician’s actual charge for the visit. The physician is not required to give the beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit. However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury.

There could be covered and noncovered procedures performed during this encounter (e.g., screening x-ray, EKG, lab tests.). These are considered individually. Those procedures which are for screening for asymptomatic conditions are considered noncovered and, therefore, no payment is made. Those procedures ordered to diagnose or monitor a symptom, medical condition, or treatment are evaluated for medical necessity and, if covered, are paid.

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All the contents and articles are based on our search and taken from various resources and our knowledge in Medical billing. All the information are educational purpose only and we are not guarantee of accuracy of information. Before implement anything please do your own research. If you feel some of our contents are misused please mail us at medicalbilling4u at gmail dot com. We will response ASAP.

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well child visit billing code

Parents know who they should go to when their child is sick. But pediatrician visits are just as important for healthy children.

The Bright Futures /American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care, known as the " periodicity schedule ." It is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence.

Schedule of well-child visits

  • The first week visit (3 to 5 days old)
  • 1 month old
  • 2 months old
  • 4 months old
  • 6 months old
  • 9 months old
  • 12 months old
  • 15 months old
  • 18 months old
  • 2 years old (24 months)
  • 2 ½ years old (30 months)
  • 3 years old
  • 4 years old
  • 5 years old
  • 6 years old
  • 7 years old
  • 8 years old
  • 9 years old
  • 10 years old
  • 11 years old
  • 12 years old
  • 13 years old
  • 14 years old
  • 15 years old
  • 16 years old
  • 17 years old
  • 18 years old
  • 19 years old
  • 20 years old
  • 21 years old

The benefits of well-child visits

Prevention . Your child gets scheduled immunizations to prevent illness. You also can ask your pediatrician about nutrition and safety in the home and at school.

Tracking growth & development . See how much your child has grown in the time since your last visit, and talk with your doctor about your child's development. You can discuss your child's milestones, social behaviors and learning.

Raising any concerns . Make a list of topics you want to talk about with your child's pediatrician such as development, behavior, sleep, eating or getting along with other family members. Bring your top three to five questions or concerns with you to talk with your pediatrician at the start of the visit.

Team approach . Regular visits create strong, trustworthy relationships among pediatrician, parent and child. The AAP recommends well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental and social health of a child.

More information

Back to School, Back to Doctor

Recommended Immunization Schedules

Milestones Matter: 10 to Watch for by Age 5

Your Child's Checkups

  • Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (periodicity schedule)

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KATHERINE TURNER, MD

Am Fam Physician. 2018;98(6):347-353

Related letter: Well-Child Visits Provide Physicians Opportunity to Deliver Interconception Care to Mothers

Author disclosure: No relevant financial affiliations.

The well-child visit allows for comprehensive assessment of a child and the opportunity for further evaluation if abnormalities are detected. A complete history during the well-child visit includes information about birth history; prior screenings; diet; sleep; dental care; and medical, surgical, family, and social histories. A head-to-toe examination should be performed, including a review of growth. Immunizations should be reviewed and updated as appropriate. Screening for postpartum depression in mothers of infants up to six months of age is recommended. Based on expert opinion, the American Academy of Pediatrics recommends developmental surveillance at each visit, with formal developmental screening at nine, 18, and 30 months and autism-specific screening at 18 and 24 months; the U.S. Preventive Services Task Force found insufficient evidence to make a recommendation. Well-child visits provide the opportunity to answer parents' or caregivers' questions and to provide age-appropriate guidance. Car seats should remain rear facing until two years of age or until the height or weight limit for the seat is reached. Fluoride use, limiting or avoiding juice, and weaning to a cup by 12 months of age may improve dental health. A one-time vision screening between three and five years of age is recommended by the U.S. Preventive Services Task Force to detect amblyopia. The American Academy of Pediatrics guideline based on expert opinion recommends that screen time be avoided, with the exception of video chatting, in children younger than 18 months and limited to one hour per day for children two to five years of age. Cessation of breastfeeding before six months and transition to solid foods before six months are associated with childhood obesity. Juice and sugar-sweetened beverages should be avoided before one year of age and provided only in limited quantities for children older than one year.

Well-child visits for infants and young children (up to five years) provide opportunities for physicians to screen for medical problems (including psychosocial concerns), to provide anticipatory guidance, and to promote good health. The visits also allow the family physician to establish a relationship with the parents or caregivers. This article reviews the U.S. Preventive Services Task Force (USPSTF) and the American Academy of Pediatrics (AAP) guidelines for screenings and recommendations for infants and young children. Family physicians should prioritize interventions with the strongest evidence for patient-oriented outcomes, such as immunizations, postpartum depression screening, and vision screening.

Clinical Examination

The history should include a brief review of birth history; prematurity can be associated with complex medical conditions. 1 Evaluate breastfed infants for any feeding problems, 2 and assess formula-fed infants for type and quantity of iron-fortified formula being given. 3 For children eating solid foods, feeding history should include everything the child eats and drinks. Sleep, urination, defecation, nutrition, dental care, and child safety should be reviewed. Medical, surgical, family, and social histories should be reviewed and updated. For newborns, review the results of all newborn screening tests ( Table 1 4 – 7 ) and schedule follow-up visits as necessary. 2

PHYSICAL EXAMINATION

A comprehensive head-to-toe examination should be completed at each well-child visit. Interval growth should be reviewed by using appropriate age, sex, and gestational age growth charts for height, weight, head circumference, and body mass index if 24 months or older. The Centers for Disease Control and Prevention (CDC)-recommended growth charts can be found at https://www.cdc.gov/growthcharts/who_charts.htm#The%20WHO%20Growth%20Charts . Percentiles and observations of changes along the chart's curve should be assessed at every visit. Include assessment of parent/caregiver-child interactions and potential signs of abuse such as bruises on uncommonly injured areas, burns, human bite marks, bruises on nonmobile infants, or multiple injuries at different healing stages. 8

The USPSTF and AAP screening recommendations are outlined in Table 2 . 3 , 9 – 27 A summary of AAP recommendations can be found at https://www.aap.org/en-us/Documents/periodicity_schedule.pdf . The American Academy of Family Physicians (AAFP) generally adheres to USPSTF recommendations. 28

MATERNAL DEPRESSION

Prevalence of postpartum depression is around 12%, 22 and its presence can impair infant development. The USPSTF and AAP recommend using the Edinburgh Postnatal Depression Scale (available at https://www.aafp.org/afp/2010/1015/p926.html#afp20101015p926-f1 ) or the Patient Health Questionnaire-2 (available at https://www.aafp.org/afp/2012/0115/p139.html#afp20120115p139-t3 ) to screen for maternal depression. The USPSTF does not specify a screening schedule; however, based on expert opinion, the AAP recommends screening mothers at the one-, two-, four-, and six-month well-child visits, with further evaluation for positive results. 23 There are no recommendations to screen other caregivers if the mother is not present at the well-child visit.

PSYCHOSOCIAL

With nearly one-half of children in the United States living at or near the poverty level, assessing home safety, food security, and access to safe drinking water can improve awareness of psychosocial problems, with referrals to appropriate agencies for those with positive results. 29 The prevalence of mental health disorders (i.e., primarily anxiety, depression, behavioral disorders, attention-deficit/hyperactivity disorder) in preschool-aged children is around 6%. 30 Risk factors for these disorders include having a lower socioeconomic status, being a member of an ethnic minority, and having a non–English-speaking parent or primary caregiver. 25 The USPSTF found insufficient evidence regarding screening for depression in children up to 11 years of age. 24 Based on expert opinion, the AAP recommends that physicians consider screening, although screening in young children has not been validated or standardized. 25

DEVELOPMENT AND SURVEILLANCE

Based on expert opinion, the AAP recommends early identification of developmental delays 14 and autism 10 ; however, the USPSTF found insufficient evidence to recommend formal developmental screening 13 or autism-specific screening 9 if the parents/caregivers or physician have no concerns. If physicians choose to screen, developmental surveillance of language, communication, gross and fine movements, social/emotional development, and cognitive/problem-solving skills should occur at each visit by eliciting parental or caregiver concerns, obtaining interval developmental history, and observing the child. Any area of concern should be evaluated with a formal developmental screening tool, such as Ages and Stages Questionnaire, Parents' Evaluation of Developmental Status, Parents' Evaluation of Developmental Status-Developmental Milestones, or Survey of Well-Being of Young Children. These tools can be found at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Screening-Tools.aspx . If results are abnormal, consider intervention or referral to early intervention services. The AAP recommends completing the previously mentioned formal screening tools at nine-, 18-, and 30-month well-child visits. 14

The AAP also recommends autism-specific screening at 18 and 24 months. 10 The USPSTF recommends using the two-step Modified Checklist for Autism in Toddlers (M-CHAT) screening tool (available at https://m-chat.org/ ) if a physician chooses to screen a patient for autism. 10 The M-CHAT can be incorporated into the electronic medical record, with the possibility of the parent or caregiver completing the questionnaire through the patient portal before the office visit.

IRON DEFICIENCY

Multiple reports have associated iron deficiency with impaired neurodevelopment. Therefore, it is essential to ensure adequate iron intake. Based on expert opinion, the AAP recommends supplements for preterm infants beginning at one month of age and exclusively breastfed term infants at six months of age. 3 The USPSTF found insufficient evidence to recommend screening for iron deficiency in infants. 19 Based on expert opinion, the AAP recommends measuring a child's hemoglobin level at 12 months of age. 3

Lead poisoning and elevated lead blood levels are prevalent in young children. The AAP and CDC recommend a targeted screening approach. The AAP recommends screening for serum lead levels between six months and six years in high-risk children; high-risk children are identified by location-specific risk recommendations, enrollment in Medicaid, being foreign born, or personal screening. 21 The USPSTF does not recommend screening for lead poisoning in children at average risk who are asymptomatic. 20

The USPSTF recommends at least one vision screening to detect amblyopia between three and five years of age. Testing options include visual acuity, ocular alignment test, stereoacuity test, photoscreening, and autorefractors. The USPSTF found insufficient evidence to recommend screening before three years of age. 26 The AAP, American Academy of Ophthalmology, and the American Academy of Pediatric Ophthalmology and Strabismus recommend the use of an instrument-based screening (photoscreening or autorefractors) between 12 months and three years of age and annual visual acuity screening beginning at four years of age. 31

IMMUNIZATIONS

The AAFP recommends that all children be immunized. 32 Recommended vaccination schedules, endorsed by the AAP, the AAFP, and the Advisory Committee on Immunization Practices, are found at https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html . Immunizations are usually administered at the two-, four-, six-, 12-, and 15- to 18-month well-child visits; the four- to six-year well-child visit; and annually during influenza season. Additional vaccinations may be necessary based on medical history. 33 Immunization history should be reviewed at each wellness visit.

Anticipatory Guidance

Injuries remain the leading cause of death among children, 34 and the AAP has made several recommendations to decrease the risk of injuries. 35 – 42 Appropriate use of child restraints minimizes morbidity and mortality associated with motor vehicle collisions. Infants need a rear-facing car safety seat until two years of age or until they reach the height or weight limit for the specific car seat. Children should then switch to a forward-facing car seat for as long as the seat allows, usually 65 to 80 lb (30 to 36 kg). 35 Children should never be unsupervised around cars, driveways, and streets. Young children should wear bicycle helmets while riding tricycles or bicycles. 37

Having functioning smoke detectors and an escape plan decreases the risk of fire- and smoke-related deaths. 36 Water heaters should be set to a maximum of 120°F (49°C) to prevent scald burns. 37 Infants and young children should be watched closely around any body of water, including water in bathtubs and toilets, to prevent drowning. Swimming pools and spas should be completely fenced with a self-closing, self-latching gate. 38

Infants should not be left alone on any high surface, and stairs should be secured by gates. 43 Infant walkers should be discouraged because they provide no benefit and they increase falls down stairs, even if stair gates are installed. 39 Window locks, screens, or limited-opening windows decrease injury and death from falling. 40 Parents or caregivers should also anchor furniture to a wall to prevent heavy pieces from toppling over. Firearms should be kept unloaded and locked. 41

Young children should be closely supervised at all times. Small objects are a choking hazard, especially for children younger than three years. Latex balloons, round objects, and food can cause life-threatening airway obstruction. 42 Long strings and cords can strangle children. 37

DENTAL CARE

Infants should never have a bottle in bed, and babies should be weaned to a cup by 12 months of age. 44 Juices should be avoided in infants younger than 12 months. 45 Fluoride use inhibits tooth demineralization and bacterial enzymes and also enhances remineralization. 11 The AAP and USPSTF recommend fluoride supplementation and the application of fluoride varnish for teeth if the water supply is insufficient. 11 , 12 Begin brushing teeth at tooth eruption with parents or caregivers supervising brushing until mastery. Children should visit a dentist regularly, and an assessment of dental health should occur at well-child visits. 44

SCREEN TIME

Hands-on exploration of their environment is essential to development in children younger than two years. Video chatting is acceptable for children younger than 18 months; otherwise digital media should be avoided. Parents and caregivers may use educational programs and applications with children 18 to 24 months of age. If screen time is used for children two to five years of age, the AAP recommends a maximum of one hour per day that occurs at least one hour before bedtime. Longer usage can cause sleep problems and increases the risk of obesity and social-emotional delays. 46

To decrease the risk of sudden infant death syndrome (SIDS), the AAP recommends that infants sleep on their backs on a firm mattress for the first year of life with no blankets or other soft objects in the crib. 45 Breastfeeding, pacifier use, and room sharing without bed sharing protect against SIDS; infant exposure to tobacco, alcohol, drugs, and sleeping in bed with parents or caregivers increases the risk of SIDS. 47

DIET AND ACTIVITY

The USPSTF, AAFP, and AAP all recommend breastfeeding until at least six months of age and ideally for the first 12 months. 48 Vitamin D 400 IU supplementation for the first year of life in exclusively breastfed infants is recommended to prevent vitamin D deficiency and rickets. 49 Based on expert opinion, the AAP recommends the introduction of certain foods at specific ages. Early transition to solid foods before six months is associated with higher consumption of fatty and sugary foods 50 and an increased risk of atopic disease. 51 Delayed transition to cow's milk until 12 months of age decreases the incidence of iron deficiency. 52 Introduction of highly allergenic foods, such as peanut-based foods and eggs, before one year decreases the likelihood that a child will develop food allergies. 53

With approximately 17% of children being obese, many strategies for obesity prevention have been proposed. 54 The USPSTF does not have a recommendation for screening or interventions to prevent obesity in children younger than six years. 54 The AAP has made several recommendations based on expert opinion to prevent obesity. Cessation of breastfeeding before six months and introduction of solid foods before six months are associated with childhood obesity and are not recommended. 55 Drinking juice should be avoided before one year of age, and, if given to older children, only 100% fruit juice should be provided in limited quantities: 4 ounces per day from one to three years of age and 4 to 6 ounces per day from four to six years of age. Intake of other sugar-sweetened beverages should be discouraged to help prevent obesity. 45 The AAFP and AAP recommend that children participate in at least 60 minutes of active free play per day. 55 , 56

Data Sources: Literature search was performed using the USPSTF published recommendations ( https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations ) and the AAP Periodicity table ( https://www.aap.org/en-us/Documents/periodicity_schedule.pdf ). PubMed searches were completed using the key terms pediatric, obesity prevention, and allergy prevention with search limits of infant less than 23 months or pediatric less than 18 years. The searches included systematic reviews, randomized controlled trials, clinical trials, and position statements. Essential Evidence Plus was also reviewed. Search dates: May through October 2017.

Gauer RL, Burket J, Horowitz E. Common questions about outpatient care of premature infants. Am Fam Physician. 2014;90(4):244-251.

American Academy of Pediatrics; Committee on Fetus and Newborn. Hospital stay for healthy term newborns. Pediatrics. 2010;125(2):405-409.

Baker RD, Greer FR Committee on Nutrition, American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics. 2010;126(5):1040-1050.

Mahle WT, Martin GR, Beekman RH, Morrow WR Section on Cardiology and Cardiac Surgery Executive Committee. Endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease. Pediatrics. 2012;129(1):190-192.

American Academy of Pediatrics Newborn Screening Authoring Committee. Newborn screening expands: recommendations for pediatricians and medical homes—implications for the system. Pediatrics. 2008;121(1):192-217.

American Academy of Pediatrics, Joint Committee on Infant Hearing. Year 2007 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007;120(4):898-921.

Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbilirubinemia in the newborn infant > or = 35 weeks' gestation: an update with clarifications. Pediatrics. 2009;124(4):1193-1198.

Christian CW Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse [published correction appears in Pediatrics . 2015;136(3):583]. Pediatrics. 2015;135(5):e1337-e1354.

Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for autism spectrum disorder in young children: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016;315(7):691-696.

Johnson CP, Myers SM American Academy of Pediatrics Council on Children with Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120(5):1183-1215.

Moyer VA. Prevention of dental caries in children from birth through age 5 years: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2014;133(6):1102-1111.

Clark MB, Slayton RL American Academy of Pediatrics Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2014;134(3):626-633.

Siu AL. Screening for speech and language delay and disorders in children aged 5 years and younger: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2015;136(2):e474-e481.

Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening [published correction appears in Pediatrics . 2006;118(4):1808–1809]. Pediatrics. 2006;118(1):405-420.

Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for lipid disorders in children and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016;316(6):625-633.

National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents. October 2012. https://www.nhlbi.nih.gov/sites/default/files/media/docs/peds_guidelines_full.pdf . Accessed May 9, 2018.

Moyer VA. Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(9):613-619.

Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published correction appears in Pediatrics . 2017;140(6):e20173035]. Pediatrics. 2017;140(3):e20171904.

Siu AL. Screening for iron deficiency anemia in young children: USPSTF recommendation statement. Pediatrics. 2015;136(4):746-752.

U.S. Preventive Services Task Force. Screening for elevated blood lead levels in children and pregnant women. Pediatrics. 2006;118(6):2514-2518.

Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials . Atlanta, Ga.: U.S. Public Health Service; Centers for Disease Control and Prevention; National Center for Environmental Health; 1997.

O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary care screening for and treatment of depression in pregnant and post-partum women: evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016;315(4):388-406.

Earls MF Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126(5):1032-1039.

Siu AL. Screening for depression in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(5):360-366.

Weitzman C, Wegner L American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics; Committee on Psychosocial Aspects of Child and Family Health; Council on Early Childhood; Society for Developmental and Behavioral Pediatrics; American Academy of Pediatrics. Promoting optimal development: screening for behavioral and emotional problems [published correction appears in Pediatrics . 2015;135(5):946]. Pediatrics. 2015;135(2):384-395.

Grossman DC, Curry SJ, Owens DK, et al. Vision screening in children aged 6 months to 5 years: U.S. Preventive Services Task Force recommendation statement. JAMA. 2017;318(9):836-844.

Donahue SP, Nixon CN Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Academy of Pediatrics; American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Visual system assessment in infants, children, and young adults by pediatricians. Pediatrics. 2016;137(1):28-30.

Lin KW. What to do at well-child visits: the AAFP's perspective. Am Fam Physician. 2015;91(6):362-364.

American Academy of Pediatrics Council on Community Pediatrics. Poverty and child health in the United States. Pediatrics. 2016;137(4):e20160339.

Lavigne JV, Lebailly SA, Hopkins J, Gouze KR, Binns HJ. The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds. J Clin Child Adolesc Psychol. 2009;38(3):315-328.

American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Visual system assessment of infants, children, and young adults by pediatricians. Pediatrics. 2016;137(1):28-30.

American Academy of Family Physicians. Clinical preventive service recommendation. Immunizations. http://www.aafp.org/patient-care/clinical-recommendations/all/immunizations.html . Accessed October 5, 2017.

Centers for Disease Control and Prevention. Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018. https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html . Accessed May 9, 2018.

National Center for Injury Prevention and Control. 10 leading causes of death by age group, United States—2015. https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_age_group_2015_1050w740h.gif . Accessed April 24, 2017.

Durbin DR American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2011;127(4):788-793.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Reducing the number of deaths and injuries from residential fires. Pediatrics. 2000;105(6):1355-1357.

Gardner HG American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Office-based counseling for unintentional injury prevention. Pediatrics. 2007;119(1):202-206.

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Prevention of drowning in infants, children, and adolescents. Pediatrics. 2003;112(2):437-439.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Injuries associated with infant walkers. Pediatrics. 2001;108(3):790-792.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Falls from heights: windows, roofs, and balconies. Pediatrics. 2001;107(5):1188-1191.

Dowd MD, Sege RD Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012;130(5):e1416-e1423.

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Prevention of choking among children. Pediatrics. 2010;125(3):601-607.

Kendrick D, Young B, Mason-Jones AJ, et al. Home safety education and provision of safety equipment for injury prevention (review). Evid Based Child Health. 2013;8(3):761-939.

American Academy of Pediatrics Section on Oral Health. Maintaining and improving the oral health of young children. Pediatrics. 2014;134(6):1224-1229.

Heyman MB, Abrams SA American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. Fruit juice in infants, children, and adolescents: current recommendations. Pediatrics. 2017;139(6):e20170967.

Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591.

Moon RY Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162940.

American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.

Wagner CL, Greer FR American Academy of Pediatrics Section on Breastfeeding; Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents [published correction appears in Pediatrics . 2009;123(1):197]. Pediatrics. 2008;122(5):1142-1152.

Huh SY, Rifas-Shiman SL, Taveras EM, Oken E, Gillman MW. Timing of solid food introduction and risk of obesity in preschool-aged children. Pediatrics. 2011;127(3):e544-e551.

Greer FR, Sicherer SH, Burks AW American Academy of Pediatrics Committee on Nutrition; Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183-191.

American Academy of Pediatrics Committee on Nutrition. The use of whole cow's milk in infancy. Pediatrics. 1992;89(6 pt 1):1105-1109.

Fleischer DM, Spergel JM, Assa'ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allergy Clin Immunol Pract. 2013;1(1):29-36.

Grossman DC, Bibbins-Domingo K, Curry SJ, et al. Screening for obesity in children and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA. 2017;317(23):2417-2426.

Daniels SR, Hassink SG Committee on Nutrition. The role of the pediatrician in primary prevention of obesity. Pediatrics. 2015;136(1):e275-e292.

American Academy of Family Physicians. Physical activity in children. https://www.aafp.org/about/policies/all/physical-activity.html . Accessed January 1, 2018.

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  1. PDF Quick Tips Coding Well-Child Visits

    A child has a well-child visit EPSDT (99381 - 99461), with a well child diagnosis code (Z-code) in the first position; the sick visit code (99211 - 99215) with the modifier 25 and with the illness diagnosis CPT code in the second position. To bill this way, there must be enough evidence in the medical record documentation to support a stand ...

  2. PDF CODING FOR Pediatric Preventive Care2022

    sick visit (99202-99215). . Codes . 99406-99409. may be reported in addition to the preventive. medicine service codes. CPT. Codes. 99406. moking and tobacco use cessation counseling visit; S ntermediate, greater than 3 minutes up to 10 minutesi. 99407. ntensive, greater than 10 minutesi. 99408. lcohol or substance (other than tobacco ...

  3. PEDIATRIC AND ADOLESCENT HEDIS CODING GUIDE 2022-2023

    Well Care CPT®: 99381-5, 99391-5, 99461 HCPCS: G0438, G0439, S0302, S0610, S0612-3 Child and Adolescent Well-Care Visits (WCV)* 3-21 years The percentage of children/adolescents 3-21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year. Addresses the adequacy of care for

  4. PDF Well-Child Visit Billing Reference Guide

    To bill for a well-child visit: Use the age-based preventive visit CPT code and appropriate ICD-10 Code listed in Table 1. Bill for each separate assessment/screening performed using the applicable CPT code from Table 2. If a screening or assessment is positive, use ICD-10 code Z00.121. If it is an issue that requires follow-up or a referral ...

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    A pediatric preventive visit (also known as a health supervision visit or well-child visit) typically includes a ... (CPT®) codes—complete with expert guidance for their application. The book's recently updated vignettes and examples, as well as the many coding pearls throughout, provide added guidance needed to ensure accuracy and payment

  6. How to Code Well Visit Done on First Sick Visit

    The preventive medicineservices codes for new patients are 99381 (under 1 year old), 99382 (1 through 4), 99383 (5 through 11), 99384 (12 through 17), and 99385 (18 through 39). The office-visit codes are 99201 through 99205. Note that the sick diagnosis code goes only on the office visit, and the well-care diagnosis code, V20.2, goes only on ...

  7. PDF Child and Adolescent Well-Care Visits (WCV)

    Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life (W34) with the Adolescent Well-Care Visits (AWC) ... CPT ® Codes. iii. Description 99382 New patient preventative medical services (ages 1-4 years) ... Z76.2 Encounter for health supervision and care of other health infant and child HCPCS Codesvi Description G0438 Annual wellness ...

  8. PDF Coding Reference Guide Measurement Year 2023 Well-Child Visits in the

    Coding Reference Guide Measurement Year 2023 Well-Child Visits in the First 30 Months of Life (W30) Tips and Best Practices to Help Improve Performance • Each encounter is an opportunity to discuss wellness and provide preventive services such as immunizations; this is

  9. PDF Examples of Proper Coding

    PC-420-NM-2022-0063 - Combined Sick and Well -Child Visits . 901 Market Street, Suite 500, Philadelphia, PA 19107 215-849-9606 . HealthPartnersPlans.com. Examples of Proper Coding Example E&M Description Well-child Visit Diagnosis Code (in the Primary Position) Well-child Visit E/M Code Allowable Sick Visits with Modifier 25

  10. Pediatric Preventive Services: Coding Quick Reference Card 2024

    This convenient card features all evaluation and management service codes, as well as other recommended service codes, for well-child visits from birth to 21 years of age. This 11″ × 11.5″ card is fully updated for 2024 and laminated for extra durability.

  11. Coding & Documentation

    We code for well-child visits using the CPT codes for a pediatric preventive exam, each vaccine and vaccine administration. Our billing company says that no more than four diagnosis codes can be ...

  12. How Your Pediatrician is Paid: Coding Information for Parents

    However, if your pediatrician follows AAP recommendations for well-child visits, he or she might report several line items for that visit: 99382 -Well-child checkup. 96110 - Brief developmental screening with scoring. 36416 - Fingerstick blood draw. 85018 - Hemoglobin blood count. Even giving a single vaccine involves 2-3 different CPT ...

  13. How to Code for a Well-Child Visit with a Sick Visit

    Code the visit as a well visit only. Also, the well-child visit will go toward the Partnership-for-Quality Program. EXAMPLE Diagnosis Code: Z00.129 (Encounter for routine child health examination without abnormal findings) CPT Code: 99392 (Established preventive medicine services code for child age 1 through 4) Documentation requirements: Must ...

  14. Documenting and Coding Preventive Visits: A Physician's Perspective

    The visits we considered were a 40-year-old established-patient preventive visit (CPT 99396), minus immunizations and other separate charges, and a level-4, established-patient, problem-oriented ...

  15. Combining a Wellness Visit With a Problem-Oriented Visit: a Coding

    Bill 99213 (or 99203 for new patients) with preventive or wellness code. An acute, uncomplicated illness at time of visit. An active, stable medical problem. Two minor problems. Remember to ...

  16. Medicaid Well-Child Visit

    Billing tips | 11 Well-child visit age or description Well-child visit ICD-10 codes New patient CPT codes Established patient CPT codes Encounter for health supervision and care of other healthy infant and child Z76.2 99202 -99205 99213 -99215 Encounter for routine child health exam with abnormal findings Z00.121

  17. PDF Well-Child Visits: Telemedicine Documentation and Billing Guide

    Billing Guide: Complete Telemedicine Visits with Specific Telemedicine Coding Visits for some age groups can be completed through telemedicine, but many should not. Please consult the Pediatric Telemedicine Clinical Recommendations by Age section for guidance. Proper telemedicine coding will be important for processing the claim correctly.

  18. Coding for Vaccine Administration

    Vaccines Administered at Well-child Visits. ... CPT Codes reported are: 99393 - Preventive service 90649 - HPV vaccine 90460 - Administration first component (1 unit) 90715 - Tdap vaccine

  19. PDF Guidance on Well-Child Visits and Preventive Care During the COVID-19

    Maryland Medicaid will provide coverage for well-child visits conducted via telehealth on a temporary basis during the COVID-19 emergency only. Refer to Table 1 for a full description of CPT codes for preventive services and any restrictions. Telehealth services for well-child visits for children older than 24 months will be covered at the

  20. CPT CODE 99381, 99382

    When conducting a well-child visit (WCV), a primary care provider (PCP) must perform all components required in a visit and all age-appropriate screenings and/or assessments as required in the DC Medicaid HealthCheck Periodicity Schedule. ... To bill for a well-child visit: * Use the age-based CPT code (99381-99385; 99391-99395). See Table 1. o ...

  21. PDF Coding Reference Guide Measurement Year 2024 Child and Adolescent Well

    Coding Reference Guide Measurement Year 2024 Child and Adolescent Well-Care Visits (WCV) Measure Description Members ages three-21 years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN provider during 2024. Documentation in the medical record must include all the following: • Health history

  22. PEDIATRIC AND ADOLESCENT HEDIS CODING GUIDE 2022-2023

    Well Care CPT®: 99381-5, 99391-5, 99461 HCPCS: G0438-9, S0302, S0610, S0612-3 Child and Adolescent Well-Care Visits (WCV)* 3-21 years The percentage of members 3-21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year. Addresses the adequacy of care for

  23. AAP Schedule of Well-Child Care Visits

    The Bright Futures/American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care, known as the "periodicity schedule." It is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence. Schedule of well-child visits. The first week visit (3 to 5 ...

  24. Well-Child Visits for Infants and Young Children

    Immunizations are usually administered at the two-, four-, six-, 12-, and 15- to 18-month well-child visits; the four- to six-year well-child visit; and annually during influenza season ...

  25. Improving the health and wellbeing of children and adolescents:guidance

    This guidance on scheduled child and adolescent well-care visits is the first in a series of publications to support the operationalization of the comprehensive agenda for child and adolescent health and wellbeing. It provides guidance on what is required to strengthen health systems and services to ensure healthy growth and development of all ...