cpt code for well baby visit

Disclaimer » Advertising

• HealthyChildren.org
• Previous Article
• Next Article

3- TO 5-DAY VISITS

Weight-check visits, other services, newborn coding in the office or outpatient setting.

• Split-Screen
• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• CME Quiz Close Quiz
• Open the PDF for in another window
• Get Permissions
• Cite Icon Cite
• Search Site

American Academy of Pediatrics; Newborn Coding in the Office or Outpatient Setting. AAP Pediatric Coding Newsletter September 2016; 11 (12): 7–8. 10.1542/pcco_book149_document003

Download citation file:

• Ris (Zotero)
• Reference Manager

Coding for services provided after discharge from the birth admission often fall into the preventive evaluation and management (E/M) service categories (eg, 99391 ). However, coding may become more complicated when a well-baby visit includes abnormal findings or a visit is scheduled due to illness or concerns about the neonate’s health.

For most newborns, the 3- to 5-day visit is the first of the outpatient preventive E/M or well-baby services they receive. These encounters are reported based on whether the patient is a new or an established patient. The newborn is an established patient if any physician of the same group practice and specialty has provided a face-to-face service to the newborn in any setting (eg, newborn care in the hospital).

International Classification of Diseases, 10th Revision, Clinical Modification ( ICD-10-CM ) codes for newborn preventive visits are age-based and do not indicate the presence or absence of abnormal findings. However, when the encounter results in an abnormal finding or a known condition is addressed at the preventive encounter, it is appropriate to use additional ICD-10-CM codes to describe signs, symptoms, or conditions addressed.

When a significant E/M service is necessary to address a problem (eg, feeding problem, jaundice) and is separately identifiable from the preventive medicine service in the record of the encounter, a problem-oriented E/M service may be reported. Append modifier 25 to the problem-oriented E/M code to denote the separate E/M service and link the ICD-10-CM code for the problem addressed to this code on the claim form. A separate problem-oriented E/M service should not be reported if a problem requires insignificant physician work (ie, key components of an E/M service are unnecessary).

A newborn diagnosed with a problem before leaving the hospital may receive only a problem-oriented E/M service (eg, 99212–99215 ) when it is necessary to follow up on the problem rather than provide a preventive service at the office.

A pediatrician sees a 3-day-old established patient for a well-baby check . The patient was a term newborn, born in the hospital, and discharged within 24 hours of birth. The newborn has a rash diagnosed as erythema toxicum. The parents are reassured that this will resolve without treatment. All other findings are normal and parents are provided the recommended anticipatory guidance.

Codes reported are

No code is reported for E/M of a problem, as the erythema toxicum did not require significant physician work.

A pediatrician sees a 3-day-old established term newborn for a well-baby visit and finds symptoms of hyperbilirubinemia. The physician conducts a detailed history and examination and decides the patient should be admitted to the hospital. The physician provides initial hospital care to the patient later that day.

The key components supported in documentation of the office and hospital care are combined to select the level of service for initial hospital care ( 99221–99223 ). Had the hospital care been provided by a physician of another specialty or other group practice, each physician would separately report his or her services.

Code Z00.111 is applicable to a weight-check visit (eg, physician ordered follow-up visit with a nurse to verify newborn is gaining weight) in a newborn 8 to 28 days of age when no abnormality is found. If the newborn is found to be losing weight or inadequately gaining, codes for the underlying reason, such as feeding problems, may be reported. CPT codes for weight-check visits may be 99211 (office E/M service not requiring presence of a physician or other qualified health care professional [QHP]) or a higher level of E/M service if problems are addressed by a physician or other QHP.

It is recommended that pediatricians screen new mothers for postpartum depression, and this is a covered preventive service under the Patient Protection and Affordable Care Act as of January 1, 2016. This screening is a reportable service when performed with a standardized screening instrument. Report the screening with code 96127 , brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument. Typically, code 96127 is reported to the health plan of the person screened—in this case, the mother. Some Medicaid and private payer plans have recognized the maternal depression screening as a risk assessment for the child when provided in conjunction with a well-child visit and provide coverage under the child’s benefit plan. It is necessary to check health plan policies on correct reporting under the baby’s or mother’s health plan. (A new code to specifically identify screening of a caregiver for the well-being of the patient has been proposed and may be added to CPT ® in 2017.) ICD-10-CM code Z13.89 (screening for other disorder) is reported for screening for postpartum depression.

See also “Coding for Services Related to Breastfeeding,” this month’s Online Exclusive, at http://coding.aap.org .

Recipient(s) will receive an email with a link to 'Newborn Coding in the Office or Outpatient Setting' and will not need an account to access the content.

Subject: Newborn Coding in the Office or Outpatient Setting

(Optional message may have a maximum of 1000 characters.)

Citing articles via

Email alerts.

Advertising Disclaimer »

Affiliations

• CEU Quizzes
• Coding Hotline
• Online ISSN 1934-5143
• Print ISSN 1934-5135
• Pediatrics Open Science
• Hospital Pediatrics
• Pediatrics in Review
• AAP Grand Rounds
• Latest News
• Pediatric Care Online
• Red Book Online
• Pediatric Patient Education
• AAP Toolkits
• AAP Pediatric Coding Newsletter

First 1,000 Days Knowledge Center

Institutions/librarians, group practices, licensing/permissions, integrations, advertising.

• Privacy Statement | Accessibility Statement | Terms of Use | Support Center | Contact Us
• © Copyright American Academy of Pediatrics

This Feature Is Available To Subscribers Only

Sign In or Create an Account

Family Life

AAP Schedule of Well-Child Care Visits

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)

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.

Medical Billing Update

• Medical billing concept – Patient 1st plan
• DOCUMENTATION OF EXAMINATION – E & M code
• Timely filing limit for BBHHF providers
• Frequency of testing considered medically necessary for ICD 9 codes
• Eligibility Verfication in Medical Billing

Recent Posts

• Denial – Covered by capitation , Modifier inconsistent – Action
• CPT code 10040, 10060, 10061 – Incision And Drainage Of Abscess
• CPT Code 0007U, 0008U, 0009U – Drug Test(S), Presumptive
• CPT code 99499 – Billing and coding guidelines
• CPT 92521,92522,92523,92524 – Speech language pathology
• Medical billing basics

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.

Coding for Vaccine Administration

Vaccine coding, vaccines administered at well-child visits.

When vaccines are provided as part of a well-child encounter, the ICD-10 guidelines instruct that code Z00.121 or Z00.129 (routine health check for child over 298 days old) includes immunizations appropriate to the patient's age. Code Z23 may be used as a secondary code if the vaccine is given as part of a preventive health care service, such as a well-child visit.ICD-10 for Combination Vaccines

ICD-10 requires only one code (Z23) per vaccination, regardless if single or combination. Report Z23 for all vaccination diagnoses.

Evaluation and Management Services Provided on the Same Date as Vaccine Administration

When an evaluation and management service (other than a preventive medicine service) is provided on the same date as a prophylactic immunization, modifier -25 may be appended to the code for the evaluation and management service to indicate that this service was significant and separately identifiable from the physician's work of the vaccine counseling/administration. Example:  A patient presents for a visit to evaluate the control of his/her diabetes and at the same visit receives an influenza vaccine administration. A physician might report code 99213-25 with diagnosis code E11.9 in addition to the appropriate flu vaccine and administration codes.

Adding National Drug Codes (NDC) to Claims

Medicaid plans and private payers may require the inclusion of a vaccine product's National Drug Code (NDC) on your claim line for each vaccine product. This can be a bit confusing if the product is labeled with a 10-digit NDC, as HIPAA requires that NDC have 11-digits. To correctly report the NDC in the HIPPA format, you may have to translate the NDC. The common format for submitting an NDC is a number that, if hyphenated, would appear in a 5-4-2 format. Some drug products are labeled in 4-4-2, 5-3-2, or 5-4-1 formats. To change these codes to the 11-digit format, a zero is placed within the product code to create the 5-4-2 format.

Here are some examples showing addition of a zero to create this format:

Reporting Administration per Component

The pediatric immunization administration with counseling codes are:

• 90460: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
• +90461: Each additional vaccine/toxoid component administered (list separately in addition to code for primary procedure)

These codes are reported per vaccine/toxoid component. CPT defines a component for these purposes as each antigen in a vaccine that prevents disease(s) caused by one organism. Combination vaccines are those vaccines that contain multiple vaccine components. You may report multiple units of code 90460 for each first vaccine/toxoid component administered. No modifier should be required when reporting multiple first components. Note also that code 90460 does not apply only to combination vaccines, but also to single component vaccines (such as influenza, human papilloma virus, or pneumococcal conjugate vaccines). This base code is reported for each vaccine administration to patients 18 years of age and under who receive counseling about the vaccine from a physician or qualified health care professional at the time of administration. Code 90461 is an add-on code reported for each additional vaccine component administered.

Report codes 90471-90474 for immunization administration of any vaccine that is not accompanied by face-to-face physician or other qualified health care professional counseling the patient and/or family, or for patients over 18 years of age.

Items of Note About Codes 90460 and 90461

To correctly report vaccine counseling and administration with these codes, it is important to recognize what the codes do and do not include.

• These codes are limited to immunization administration, meaning purchased vaccine products must be separately reported.
• A face-to-face service where a physician or other qualified health care professional (qualified per state licensure) provides counseling to the patient and/or caregivers is required to report 90460-90461.  
• In the absence of counseling, the administrations must be reported with codes 90471-90474.
• 90460-90461 are reported for administration to patients 18 years of age and under.
• Code 90460 is reported for each separate administration of single component vaccines and/or first component of a combination vaccine.
• When reporting administration of combination vaccines, code 90460 is reported for the first component and add-on code 90461 is reported for each additional component (no modifier -51 required).
• Note that route of administration (whether injection, oral, or intranasal) does not matter, since the codes include “via any route of administration.”

Administration Coding Example

An 11-year old girl presents for a preventive visit (99393). In addition, the child and her mother are counseled by the physician on risks and benefits of HPV (90649), Tdap (90715) and seasonal influenza (90660) vaccines. The physician documents the discussion. The mother signs consent to administration of these vaccines. A nurse prepares and administers each vaccine, completes chart documentation and vaccine registry entries, and verifies there is no immediate adverse reaction.

CPT Codes reported are: 99393 - Preventive service 90649 - HPV vaccine 90460 - Administration first component (1 unit) 90715 - Tdap vaccine 90460 - Administration first component (1 unit) 90461 - 2 additional components (2 units) 90660 - Influenza vaccine, live, for intranasal use 90460 - Administration first component (1 unit)

 Also in this Section

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

Internet Explorer Alert

It appears you are using Internet Explorer as your web browser. Please note, Internet Explorer is no longer up-to-date and can cause problems in how this website functions This site functions best using the latest versions of any of the following browsers: Edge, Firefox, Chrome, Opera, or Safari . You can find the latest versions of these browsers at https://browsehappy.com

• Publications
• HealthyChildren.org

Shopping cart

Order Subtotal

Your cart is empty.

Looks like you haven't added anything to your cart.

• Career Resources
• Philanthropy
• About the AAP
• The Role of the Pediatrician in the Promotion of Healthy, Active Living
• How Can You Support Patients in Healthy, Active Living? Check Out Updated Report
• Helping Kids Build Healthy Active Lives: AAP Policy Explained
• Climate Change & Children’s Health: AAP Policy Explained
• News Releases
• Policy Collections
• The State of Children in 2020
• Healthy Children
• Secure Families
• Strong Communities
• A Leading Nation for Youth
• Transition Plan: Advancing Child Health in the Biden-Harris Administration
• Health Care Access & Coverage
• Immigrant Child Health
• Gun Violence Prevention
• Tobacco & E-Cigarettes
• Child Nutrition
• Assault Weapons Bans
• Childhood Immunizations
• E-Cigarette and Tobacco Products
• Children’s Health Care Coverage Fact Sheets
• Opioid Fact Sheets
• Advocacy Training Modules
• Subspecialty Advocacy Report
• AAP Washington Office Internship
• Online Courses
• Live and Virtual Activities
• National Conference and Exhibition
• Prep®- Pediatric Review and Education Programs
• Journals and Publications
• NRP LMS Login
• Patient Care
• Practice Management
• AAP Committees
• AAP Councils
• AAP Sections
• Volunteer Network
• Join a Chapter
• Chapter Websites
• Chapter Executive Directors
• District Map
• Create Account

• Materials & Tools
• Clinical Practice
• States & Communities
• Quality Improvement
• Implementation Stories

Learn About Coding for Pediatric Preventive Care

The AAP provides coding newsletters and fact sheets that outline the various ​codes for patient visits. View the 2022 Coding for Pediatric Preventive Care Booklet ​​. ​

For more information, visit  Coding and Valuation  to learn about:

• Tools for Payment
• Resources to Educate
• Solutions for Coding Challenges

For specific coding questions, submit via the AAP Coding Hotline ​.

Last Updated

American Academy of Pediatrics