Billing for well-baby visits, covered under CPT code 99391, is a critical part of ensuring a positive financial performance for your pediatric practice. However, it comes with its fair share of unique challenges.
For instance, you must append an appropriate modifier and follow documentation requirements to ensure rightful and timely reimbursement. Without proper knowledge, errors are likely to occur, resulting in a higher denial rate and a strained revenue cycle.
This guide covers everything you need to know about billing these well-baby visits, from modifier application to documentation requirements. Therefore, if you are a pediatrician struggling to receive your rightful reimbursement, read this guide till the end!
CPT Code 99391 – Description
CPT 99391 is related to preventive medicine services. It means the physician provides care services to patients who do not require any immediate medical attention. However, a periodic health checkup is deemed necessary as a preventive measure.
If we review the descriptor of CPT code 99391 specifically, it covers well-baby visits for infants (0-1 year old). During the encounter, the pediatrician conducts a detailed review of systems and past, family, and social history (PFSH). Based on the collected data, the physician then assesses age and gender-related risk factors.
That’s not all! The pediatrician may also order various diagnostic or laboratory tests and administer immunizations as part of the preventive service.
Moreover, this procedural code covers periodic health checkups for established infants only.
Note: Medicare does not cover this service.
Scenarios Where CPT Code 99391 is Applicable
Discussed below are some of the real-world clinical scenarios to help you gain a better understanding of where CPT 99391 applies:
Well-Baby Visit for a 2-Month-Old
Picture a 2-month-old infant brought in by the parents for a routine well-baby visit to the same pediatrician who performed the newborn checkup.
The pediatrician performs a comprehensive physical assessment and reviews the developmental milestones. Moreover, the physician addresses the parents’ concerns related to sleep patterns and feeding.
This well-care visit ends with the administration of age-appropriate immunizations.
Here, CPT code 99391 applies.
Well-Baby Visit for a 6-Month-Old
Imagine an established 6-month-old infant scheduled for a routine well-baby checkup. The physician performs a detailed physical examination and discusses the best practices for introducing solids.
For context, starting from 6 months, parents should introduce 2-3 spoonfuls of soft food, e.g., mashed vegetables or fruits, porridge, etc.
During the visit, the pediatrician also assesses the baby’s gross motor skills, including rolling and sitting.
Additionally, the physician conducts a risk assessment for developmental delays and orders some blood tests as part of standard preventive care.
The pediatrician will report CPT code 99391 to bill for this visit.
Well-Baby Visit for a 9-Month-Old
Assume a 9-month-old baby who visits the pediatrician with parents for a routine health checkup. The provider conducts a comprehensive physical assessment and evaluates age-appropriate milestones, including pincer grasp and crawling. He also discusses home-safety measures, such as choking hazards, and baby-proofing.
The pediatrician also checks the baby’s hearing and vision and requests a lead screening as part of preventive measures. Since the established patient well-baby visit covers all this, the pediatrician will report CPT code 99391.
Applicable Modifiers for CPT Code 99391
The following are the two essential modifiers you should be familiar with while billing CPT 99391:
Modifier 25
What happens when the same physician renders an evaluation and management (E/M) service (99211-99215) for the same patient on the same day to address an illness discovered during the preventive care service (CPT code 99391)?
You append modifier 25 to the E/M code to indicate that the service is significant and separately identifiable. It is an integral modifier that helps you bypass unnecessary bundling of services and ensure accurate reimbursement.
Modifier GY
As discussed before, Medicare does not cover CPT 99391. So, what happens when you perform this service with an E/M service (99211-99215)? Do you report E/M service with modifier 25 and bill 99391 without a modifier?
No! You append modifier GY to CPT code 99391 to initiate an automatic denial for this service since it is a non-covered service under the patient’s insurance plan.
However, note that some private payers may cover this well-baby visit. Thus, strive to verify coverage details and benefits with the relevant payer before submitting the claim.
CPT Code 99391 – Billing & Reimbursement Guidelines
Here, let’s take a look at the key billing and reimbursement guidelines related to CPT 99391:
Documentation Requirements
When submitting a claim for CPT code 99391, you must ensure complete and accurate documentation. That is, it must include:
- Detailed patient history, including systems assessment and review of the family, social, and past medical history.
- Clinical notes on a comprehensive physical examination appropriate to the patient’s gender and age.
- Clinical notes on a thorough assessment of gender and age-related risk factors.
- Mention of immunization administration (if any) and details related to the counselling on topics, including developmental milestones, safety, and nutrition.
Do Not Bill CPT Code 99391 for Children Older Than 1 Year
This preventive medicine code is specifically for children aged 0 to 12 months old. Therefore, if the patient’s age is older than this, this code does not apply. Billing it will result in a claim denial due to a coding error.
Moreover, avoid reporting it if it is the first well-baby visit since CPT code 99381 is available for new patient well-baby visits of infants under the age of one.
Understand Payer-Specific Policies
Reimbursement guidelines and billing requirements significantly vary across federal programs (e.g., Medicare) and commercial payers. Therefore, strive to stay current on relevant payer policies before submitting a claim. It will help you avoid denials and enhance the claim first-pass ratio.
Summary
With that said, it is time to wrap up this comprehensive guide. But before concluding, let’s quickly summarize everything that we discussed.
First, we explained the CPT code 99391 descriptor. It covers well-baby visits for infants 0-1 years old (established patients).
Next, we shared a few real-world clinical scenarios to help you understand its application. These include well-baby visits for 2, 6, and 9-month-olds.
We also listed the applicable modifiers when billing CPT 99391, including 25 and GY.
Finally, we discussed the billing and reimbursement guidelines related to this preventive medicine procedural code.Hopefully, these details will help you hone your billing skills when it comes to reporting these periodic routine checkups. However, if you struggle, feel free to outsource and explore MediBillMD’s suite of pediatric billing services.
