Healthcare providers working with pediatric patients know the importance of comprehensive preventive care. The first year after birth is the most vital for patients. Any negligence in treatment or diagnosis can severely harm the child in the long term. However, pediatric preventive care is also a major source of revenue for healthcare providers.
In 2024 alone, over 3.6 million births were recorded in the United States. Although the overall birth rate is declining in the country, this remains a substantial number. More births mean more patients and more claims. A frequently used code in pediatric practices is CPT code 99381. Providers must use this code correctly. Otherwise, they might lose a lot of revenue.
Don’t worry, we have got you covered. Our billing experts at MediBillMD have broken down code 99381 in detail. So, let’s start.
CPT Code 99381 – Description
CPT code 99381 is defined as:
“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).”
The definition is self-explanatory, but let’s break it down for clarity.
Code 99381 is specifically used for a well-baby visit for children under the age of 1. The services provided under 99381 are comprehensive and include ordering any necessary laboratory tests. Additionally, the patient must be new to the pediatrician or that practice.
Please note that CPT code 99381 is part of the preventive medicine services category (codes 99381-99397) and should not be confused with problem-oriented evaluation and management (E/M) codes (99202-99215).
Many billers confuse the CPT code with similar problem-oriented evaluation and management codes (99202-99215). This simple mistake often results in claim denials and, in turn, loss of revenue. As a biller, you must understand the difference between preventive services codes and problem-oriented E/M codes.
Scenarios Where CPT Code 99381 is Applicable
If the description did not clear up some of your confusion about CPT code 99381, let’s look at some real-world scenarios in which it can be used.
An Infant’s First Pediatric Visit
Suppose a 2-month-old baby is brought to a pediatric practice for a routine checkup. The pediatrician performs a detailed examination of the baby, including growth measurements, developmental screening, and immunization review. The physician also provides some guidance to the parents regarding feeding, sleep safety, and developmental milestones. In this scenario, the physician can bill the entire encounter using CPT code 99381.
Well-Baby Visit with Minor Concerns
A 6-month-old infant presents for a routine well-baby examination. His parents mention minor concerns about sleep patterns and feeding schedules. The provider addresses these concerns as part of anticipatory guidance while completing the comprehensive preventive examination. Since the concerns don’t require significant additional evaluation or treatment planning, CPT 99381 remains appropriate without additional E/M codes.
Applicable Modifiers for CPT Code 99381
Sometimes the situation is not straightforward, and you may have to use modifiers to provide details about the circumstances and medical evaluation. The following are some of the frequently used modifiers with 99381:
| Modifer | Description |
|---|---|
| 25 | Used to indicate a separately identifiable E/M service |
| 59 | Used to indicate that the service is distinct from other services performed on the same day |
| EP | When a full or partial screening is performed |
Please note that modifier EP is only used for patients with Medicaid coverage. It is used when service is part of an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.
Also, proper documentation is required to justify the use of modifiers. For instance, if you use modifier 25 in your claims, the documentation must clearly demonstrate that additional work was performed beyond the preventive service. In this case, you must separate the preventive services (99381) from problem-oriented evaluation and management. The modifier 25 will be appended with the later CPT code.
CPT Code 99381 – Billing & Reimbursement Guidelines
You must follow the code-specific billing best practices and reimbursement guidelines to mitigate claim denials. We have mentioned some below for CPT code 99381.
Confirm Insurance Coverage
Code 99381 has a status indicator “N” on CMS guidelines. This means that Medicare does not reimburse for this code. Medicare uses this code for tracking purposes only. Also, please note that according to CMS guidelines, Medicare has established specific HCPCS codes for preventive services:
- G0402: Initial Preventive Physical Examination (IPPE)
- G0438: Annual Wellness Visit, initial visit
- G0439: Annual Wellness Visit, subsequent visit
So, if your patient has Medicare coverage, you must use these specific HCPCS codes instead of CPT code 99381. However, some private insurance companies, such as Cigna and Aetna, cover the cost for code 99381.
Include Supporting Documentation
Proper documentation is essential for supporting CPT code 99381 billing. The medical record must include:
- Age-appropriate comprehensive history, including birth history, feeding patterns, sleep habits, and developmental milestones.
- Complete physical examination appropriate for the infant’s age.
- Growth measurements (weight, length, head circumference) with percentile documentation.
- Developmental screening and assessment.
- Immunization status review and administration as appropriate.
- Anticipatory guidance provided to caregivers.
- Risk factor identification and intervention strategies.
- Plans for follow-up care and next preventive visit.
Wrapping Up
CPT code 99381 is frequently used in pediatric practices for well-baby visits. Healthcare providers must bill this code correctly to ensure fair reimbursement. However, the key point to note is that Medicare does not reimburse for this code and uses its own HCPCS codes for preventive services.
In this guide, we have simplified everything you need to know about CPT code 99381. However, if you are still facing difficulty with pediatric codes or claim denials, consider employing our expert pediatric billing services.
