Preventive care is an essential checkup that helps patients maintain a healthy lifestyle. This checkup detects early signs of potential illnesses, manages chronic conditions, and reduces overall healthcare costs.
However, the billing challenges still exist for the healthcare professionals providing preventive care. Hence, this blog discusses every essential detail about CPT code 99384, which is used to bill preventive care services for youngsters between the ages of 12 and 17.
If you are interested in finding out what this code covers and its billing requirements, read this comprehensive blog.
CPT Code 99384 – Description
CPT code 99384 is an Evaluation and Management (E/M) code that refers to an initial comprehensive preventive medicine evaluation or wellness visit.
During this procedure, the provider performs a thorough health checkup to evaluate an individual’s overall health status. In this case, the patient must be an adolescent between the ages of 12 and 17 who meets the definition of a new patient.
Note that a new patient is someone who has not received any professional medical services from the physician or another qualified healthcare professional of the same specialty within the past three years.
Scenarios Where CPT Code 99384 is Applicable
Here are some examples to help you understand the description of CPT code 99384.
Annual Pediatric Checkup
Suppose a family has moved to a new city. They present their 13-year-old son to a new healthcare practice for an annual wellness checkup. The physician performs a comprehensive preventive evaluation, including growth measurements, developmental assessments, a review of past illnesses, recording of family history, and a general health screening.
After the evaluation, the physician instructs his parents on his diet, sleep schedule, and mental health for better growth and overall well-being.
Since the patient is new and the service is a preventive medicine examination, CPT code 99384 should be used.
Preventive Checkup for Sports
A 16-year-old girl, who has never been seen by a family practice clinic before, comes in for a school sports physical examination required for participation in basketball. The provider conducts a comprehensive physical exam, reviews her health history, checks vision, heart, lungs, and musculoskeletal system, and discusses injury prevention and proper hydration. The physician also verifies that her immunizations are up to date.
Because this is a new patient receiving a preventive wellness visit rather than treatment for an illness, CPT code 99384 applies.
Applicable Modifiers for CPT Code 99384
The following are some essential modifiers that you may apply with CPT code 99384 according to the payer’s requirements.
Modifier 25
Modifier 25 refers to a significant and separately identifiable E/M service. However, this modifier can only be appended to CPT code 99384 if the same physician performed a distinct procedure and the well-child visit on the same day for the same new patient.
Modifier 33
Modifier 33 is used to indicate to the commercial payers that the given service is preventive care designated by the Affordable Care Act (ACA). It helps patients avoid paying copays, deductibles, and coinsurances.
Modifier 52
You must apply modifier 52 with modifier EP when all components of the wellness visit were not met, but at least the first 5 or more components were completed according to the Healthy Children & Youth/Early Periodic Screening, Diagnostic, and Treatment (HCY/EPSDT) requirements.
Modifier EP
Insurance payers require the modifier EP to be used with CPT code 99384 to indicate that full or partial preventive services were provided to a Medicaid beneficiary as per the HCY/EPSDT requirements. The modifier is specifically used for Medicaid-eligible children and youth, i.e., those under 21 years.
CPT Code 99384 – Billing & Reimbursement Guidelines
Here are some billing guidelines that you may follow to bill CPT code 99384 accurately.
Ensure the Correct Use 99384
The most important factor to keep in mind while billing CPT code 99384 for preventive care services is the patient’s age. This code is only used to bill preventive services provided to children between 12 and 17. A wellness visit for any patient above or below this age must be billed with other more relevant CPT codes.
Include Detailed Documentation
Documentation is used to establish the medical necessity of the procedure and to provide valid proof of the services. Hence, missing vital details in your paperwork can affect your reimbursement rate. The following is essential information for CPT code 99384 that you must provide with your claim to secure the chances of getting paid accurately:
- Anticipatory guidance
- Screenings performed
- Medical, family, and social history
- The age of the patient
- Purpose of the visit
- Reports of the physical exam
- Interventions to reduce risk factors
Comply with Payers’ Rules
From federal and state payers to commercial payers, everyone has their own way of processing medical claims and reimbursing healthcare professionals. For example, the reimbursement rate for 99384 varies between $153.78 and $203.79, depending on the payer. So you must check payers’ policies, billing requirements, and reimbursement rates to ensure compliant claim submission. This advice must be considered for modifier application and supporting documentation preparation, too, because accepted modifiers and documentation needs also vary from payer to payer.
Final Words
We have discussed everything necessary to bill CPT code 99384, from explaining the code descriptor with practical examples to discussing important guidelines for documentation and billing.
However, if, even after reading this, you are facing issues with billing your services, we highly recommend partnering with MediBillMD for expert pediatric billing services. Their professional team will help you streamline your workflow by reducing errors in claims and submitting clean claims efficiently.
