cpt code pediatric well visit

CPT CODE 99391, 99395, 99396, 99397, 99394 – Preventive Exam

Sep 12, 2016 | Medical billing basics

CPT CODE AND Description

99391 – Periodic comprehensive preventive medicine reevaluation 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, established patient; infant (age younger than 1 year) – Average fee amount $90

99392 – Periodic comprehensive preventive medicine reevaluation 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, established patient; early childhood (age 1 through 4 years)  Average fee amount $105 99393 – Periodic comprehensive preventive medicine reevaluation 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, established patient; late childhood (age 5 through 11 years) Average fee amount $110

99394 – Periodic comprehensive preventive medicine reevaluation 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, established patient; adolescent (age 12 through 17 years) Average fee amount $120

99395 – Periodic comprehensive preventive medicine reevaluation 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, established patient; 18-39 years 99396 – Periodic comprehensive preventive medicine reevaluation 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, established patient; 40-64 years 99397 – Periodic comprehensive preventive medicine reevaluation 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, established patient; 65 years and older

Referral/notification/preauthorization requirements

There are no referral/preauthorization requirements for well baby/well child care visits when provided by a contracted FCHP primary care physician within the member’s product network.

Billing/coding guidelines

For new patients making a well baby/well child care visit:

• For infants under age 1, use CPT code 99381.

• For children ages 1 to 4 (early childhood), use CPT code 99382.

• For children ages 5 to 11 (late childhood), use CPT code 99383.

• For children ages 12 to 17 (adolescent), use CPT code 99384.

• For children age 18 (adolescent), use CPT code 99385.

For established patients making a well baby/well child care visits:

• For infants under age 1, use CPT code 99391.

• For children ages 1 to 4 (early childhood), use CPT code 99392.

• For children ages 5 to 11 (late childhood), use CPT code 99393.

• For children ages 12 to 17 (adolescent), use CPT code 99394.

• For children age 18 (adolescent), use CPT code 99395.

Preventive Medicine Visits • Not all insurers pay for preventive medicine visits. For example, these visits are not covered by Medicare.

If you suspect a patient does not have coverage, advise him or her of your billing policies.

• Insurers that do cover preventive medicine visits (eg, many HMOs) generally reimburse them at relatively high rates.

• Regardless of whether a preventive medicine visit is covered, the relevant codes can be used alone or in conjunction with a code for an E&M service (see below).

Patient and Visit Preventive Medicine Code

New patient, initial visit Age 40 through 64 years 99386 Age 65 years and older 99387 Established patient, periodic visit Age 40 through 64 years 99396 Age 65 years and older 99397

Preventive Medicine Services: Established Patients

Periodic comprehensive preventive medicine reevaluation and management of an individual includes an age- and gender-appropriate history; physical examination; counseling, anticipatory guidance, or risk factor reduction interventions; and the ordering of laboratory or diagnostic procedures. CPT Codes                        ICD-9-CM Codes

99391 Infant (younger than 1 year)           V20.31 Health supervision for newborn under 8 days old

                                             V20.32 Health supervision for newborns 8 to 28 days old

                                             V20.2 Routine infant or child health check

99392 Early childhood (age 1–4 years)        V20.2 Routine infant or child health check

99393 Late childhood (age 5–11 years)        V20.2 Routine infant or child health check

99394 Adolescent (age 12–17 years)           V20.2 Routine infant or child health check

99395 18 years or older                V70.0 Routine general medical examination  at a health care facility

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 pre  existing 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 the 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.existing 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 the 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.

Policy Statement

Preventive medicine services 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 diseaserelated diagnoses. Occasionally, an abnormality is encountered or a pre-existing problem is addressed during the preventive visit, and significant elements of related E/M services are provided during the same visit. When this occurs, Medica will reimburse the preventive medicine E/M service at the contracted rate and the problem-oriented E/M service at 75% of the contracted rate, when appended with modifier 25.

Procedure codes used to bill preventive medicine services are:

** Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397

During a visit for a preventive medicine service, other services may be provided.

HealthWatch EPSDT codes PLUS Evaluation & Management (E&M) Codes PLUS Modifier 25* 

PLUS ICD-9 Diagnosis Codes 99381–99385or 99391–99395

The components of the EPSDT visit must be provided and documented.

99203–99215 The presenting problem must be of moderate to high severity Documentation  must support the use of a modifier 25

V20.2 must be the primary diagnosis code for the preventive visit Add multiple diagnosis codes for the presenting problem focused evaluation.

THE PREVENTIVE SERVICE E/M VISIT WITH A PROBLEM-ORIENTED SERVICE: AN EXAMPLE

A 52-year-old established patient presents for an annual exam. When you ask about his current complaints, he mentions that he has had mild chest pain and a productive cough over the past week and that the pain is worse on deep inspiration. You take additional history related to his symptoms, perform a detailed respiratory and CV exam, and order an electrocardiogram and chest X-ray. You make a diagnosis of acute bronchitis with chest pain and prescribe medication and bed rest along with instructions to stop smoking. You document both the problem-oriented and the preventive components of the encounter in detail. You should submit 99396, “Periodic comprehensive preventive medicine…, established patient; 40-64 years” and ICD-9 code V70.0, “Routine general medical examination at a health care facility”; and the problem-oriented code that describes the additional work associated with the evaluation of the respiratory complaints with modifier -25 attached, ICD-9 codes 466.0, “Acute bronchitis” and 786.50, “Chest pain” and the appropriate codes for the electrocardiogram and chest X-ray.

Bill Diagnosis code(s) V70.0

Routine exam Procedure code(s) 99396

Preventive service 466.0 786.50

Acute bronchitis  Chest pain 99213-25*

Office outpatient E/M service for established patient 93000

Electrocardiogram 71020

Chest X-ray, PA and lateral

*The level of service represents only an example. The level reported should be determined by the documented history, exam and/or medical decision-making.

CPT Code for Initial Evaluation of New Patient (Bold)

CPT Code for Periodic Reevaluation

99381 – 99391 – Under 1 year

99382 – 99392 – 1-4

99383 – 99393 – 5-11

99384 – 99394 – 12-17

99385 – 99395 – 18-39

99386 – 99396 – 40-64

99387 – 99397 – 65 and over

Code 99420 is specific to administration and interpretation of health risk assessment instruments.

Payers may or may not allow use of this code for behavior-related questionnaires such as the Pediatric Symptom Checklist or one of the longer alcohol- or depression-related questionnaires.

Finally, the last of the preventive medicine codes is 99429, Unlisted Preventive Medicine Service. Practitioners are urged to check with the managed care plan or insurance carrier before using this code.

PREVENTIVE CODES THAT SHOULD GENERALLY BE COVERED AT NO OUT OF POCKET COST FOR BCBSIL HMO MEMBERS  Preventive Medicine Services – Adult Established Patient: 99394 – adolescent (12-17) 99395 – 18-39 years 99396 – 40-64 years 99397 – 65 years and older Preventive Medicine Services – Pediatric Established patient: 99391 – age younger than 1 year 99392 – age 1-4 years 99393 – age 5-11 years

99211 99212 99213 99214 99215 Mutually Exclusive   99391 99392 99393 99394 99395 99396 99397

Therefore, 99211-99215 is submitted with 99391-99397–only 99391-99397 reimburses.

Preventive Medicine Evaluation & Management (E&M) Services

 *  Preventive Medicine E&M services should be reported using the age appropriate code from the Preventive Medicine Services section of the most current CPT manual.

* Services rendered should be reported using 99381-99387 for new patients or 99391-99397 for established patients. These codes include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination.

*  If an abnormality/ies is encountered, or a preexisting problem is addressed in the process of performing a preventive medicine E&M service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a  problem-oriented E&M service, then the appropriate  office/Outpatient code 99201-99215 should also be reported.

Modifier-25 should be added to the Office/Outpatient code to indicate that a significant; separately identifiable E&M service was provided by the same physician on the same day as the preventive medicine service. Note: An insignificant or trivial problem or abnormality that is encountered in the process of performing the preventive medicine E&M service and which does not require additional work and the performance of the key components of a problem-oriented E&M service should not be reported.

Evaluation and management services including new or established patient office or other outpatient services (99201-99215), emergency department services (99281-99285), nursing facility services (99304-99318), domiciliary, rest home, or custodial care services (99324-99337), home services (99341-99350), and preventive medicine services (99381-99397) on the same date related to the admission to “observation status” should not be reported separately.” (AMA7)

“An E&M service is separately reportable on the same date of service as a procedure with a global period of 000, 010, or 090 under limited circumstances…If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.

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.

Screening Services

The comprehensive nature of a Preventive Medicine code reflects an age and gender appropriate examination. When a screening code is billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Prolonged Services

Prolonged services codes represent add-on services that are reimbursed when reported in addition to an appropriate primary service. Preventive medicine services are not designated as appropriate primary codes for the Prolonged services codes. When Prolonged service add-on codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Counseling Services

Preventive Medicine Services include counseling. When counseling service codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Medical Nutrition Therapy Services

According to CPT, for Medical Nutrition Therapy assessment and/or intervention performed by a physician, report Evaluation and Management or Preventive Medicine service codes. When Medical Nutrition Therapy codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Visual Function and Visual Acuity Screening

The comprehensive nature of a Preventive Medicine code reflects an age and gender appropriate examination. When Visual Function Screening or Visual Acuity Screening is billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Preventive Medicine Service Provided at the Time of Covered Screening Service

A preventive medicine exam, as described by CPT-4 codes (99384 – 99397), includes a comprehensive age and gender appropriate history, examination, counseling/anticipatory guidance/risk-factor reduction interventions, and the ordering of appropriate immunization(s) and laboratory/diagnostic procedures. Sometimes these other elements are performed during the same visit as the Medicare covered services, particularly G0101 and Q0091. The following pie chart illustrates this circumstance.

The following are examples of screening services that are ineligible for separate reimbursement when reported with preventive medicine services, annual GYN examinations and/or problem oriented E/M services:

• G0101 is included in the reimbursement for:

o problem oriented E/M services (99201-99215)*

o preventive medicine services (99381-99397)

o annual GYN examinations (S0610, S0612, or S0613)

• G0102 is included in the reimbursement for:

• Q0091 is included in the reimbursement for:

o preventive medical services (99381-99397)*

o annual GYN examinations (S0610, S0612, or S0613)*

• S0610, S0612, and/or S0613 is included in the reimbursement for:

Coding for a Problem Focused Visit Within an EPSDT Visit

EPSDT codes

99381–99385 or 99391-99395 The components of the EPSDT visit must be provided and documented

PLUS Evaluation and Management (E&M)codes

99203–99215 The presenting problem must be of moderate to high severity.

PLUS Modifier 25*

Documentation must support the use of modifier 25.

PLUS ICD-9 Diagnosis codes

V20.2 or V70.0 must be the primary diagnosis diagnosis code for the visit. Add the diagnosis codes for the presenting problem focused evaluation.

Effective 4/1/2014 EPSDT/Well Child visits are all-inclusive visits. The payment for the EPSDT is intended to cover all elements outlined in the AHCCCS EPSDT Periodicity Schedule (AMPM Exhibilt 430-1). Refer to AMPM Policy 430 for exceptions to the all-inclusive visit global payment rate. Claims must be submitted on CMS 1500 form. Providers must bill for preventative EPSDT services using the preventative service, office or other outpatient services and preventative medicine CPT codes (99381 – 99385, 99391 – 99395) with an EP modifier. EPSDT visits are paid at a global rate for the services specified in AMPM Policy 430. No additional reimbursement is allowed.

Providers must use an EP modifier to designate all services related to the EPSDT well child check-up, including routine vision and hearing screenings.

Providers must be registered as Vaccines for Children (VFC) Program providers and VFC vaccines must be used. Under the federal VFC program, providers are paid a capped fee for administration of vaccines to recipients 18 years old and younger. For VFC claims incurred prior to 1/1/2013, Providers must bill the appropriate CPT code for the immunization with the “SL” (State supplied vaccine) modifier that identifies the immunization as part of the VFC program.

Providers must not use the immunization administration CPT codes 90471, 90472, 90473, and 90474 when billing under the VFC program. Because the vaccine is made available to providers free of charge, providers must not bill for the vaccine itself.

For VFC services incurred on/after 1/1/2013, Section 1202 of the Patient Protection and Affordable Care Act (ACA) requires AHCCCS to modify how providers submit claims for vaccine administration services.

EPSDT CPT codes well-child visits STAGE (Age) NEW PATIENT CPT CODE ESTABLISHED PATIENT CPT CODE

INFANCY (Prenatal – 9 months) 99381 99391 EARLY CHILDHOOD (12 months – 4 years) 99382 99392 MIDDLE CHILDHOOD (5 years – 10 years) 99383 99393 ADOLESCENCE STAGE 1 (11 years – 17 years) 99384 99394 ADOLESCENCE STAGE 2 (18 years – 21 years) 99385 99395 EPSDT CPT codes for sensory screening SERVICE CPT CODE VISION 99173 HEARING (Audio) 92551 HEARING (Pure tone-air only) 92552 Adult annual preventive care visits

New patient

CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older

Established patient

CPT Code 99395: Periodic Preventive Medicine Established Patient 18-39 years CPT Code 99396: Periodic Preventive Medicine Established Patient 40-64 years CPT Code 99397: Periodic Preventive Medicine Established Patient 65 years & older Adolescent annual preventive care visits

CPT Code 99382: Initial Preventive Medicine New Patient age 1-4 years CPT Code 99383: Initial Preventive Medicine New Patient age 5-11 years CPT Code 99384: Initial Preventive Medicine New Patient age 12-17 years

CPT Code 99392: Periodic Preventive Medicine Established Patient age 1-4 years CPT Code 99393: Periodic Preventive Medicine Established Patient age 5-11 years CPT Code 99394: Periodic Preventive Medicine Established Patient age 12-17 years

Preventive Visit Codes Although preventive visit codes will be accepted (99385; 99386; 99387; 99395; 99396; 99397), Medicare does not establish a rate for these codes. Sage will pay 99385 – 99387 at the rate for code 99203. Codes 99395 – 99397 will be paid at the rate for code 99213.

PARTIAL SCREENING and Modifier usage

Different providers may provide segments of the full medical screen. The purpose of this is to increase the access to care for all children and to allow providers reimbursement for those separate screens. When expanded HCY services are accessed through a partial or interperiodic screen, it is the responsibility of the provider completing the partial screening service to have a referral source to refer the child for the remaining components of a full screening service. An unclothed physical and history screen ( CPT codes 99381 52 EP-99385 52EP and 99391 52 EP -9939552EP) includes the first five sections of the age appropriate screening guide including:

• Interval history; • Unclothed physical exam; • Anticipatory guidance; • Laboratory/Immunizations; and • Age appropriate lead screening. Federal regulations require a mandatory blood lead testing by either capillary or venous method at 12 months and 24 months of age. The provider must use the HCY Lead Risk Assessment form.

PARTIAL SCREENING PROCEDURE CODES – UNCLOTHED PHYSICAL & HISTORY (Established Patient) (Provider must complete Sections 1-5 of the HCY Screening Guide)

Procedure Code (Use Age Appropriate Code) Modifier 1 Modifier 2 Fee

99391* 52 EP $20.00 99392* 52 EP $20.00 99393* 52 EP $20.00 99394* 52 EP $20.00 99395* 52 EP $20.00

*Modifier “UC” must be used if child was referred for further care as a result of the screening. DESCRIPTION OF MODIFIERS USED FOR HCY SCREENINGS

* EP – Service provided as part of MO HealthNet early periodic, screening, diagnosis, and treatment (EPSDT). * 52 – Reduced services. Modifier 52 must be used when all the components for the unclothed physical and history procedure codes (99381-99395) have not been met according to CPT. Also used with procedure code 99429 to identify that the components of a partial HCY vision screen have been met. * 59 – Distinct Service. Modifier 59 must be used to identify the components of an HCY screen when only those components related to developmental and mental health are being screened. * UC – EPSDT Referral for Follow-Up Care. The modifier UC must be used when the child is referred on for further care as a result of the screening.

All Preventive CPT CODE AND description Adult preventive care visits New patient CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older

Established patient CPT Code 99395: Periodic Preventive Medicine Established Patient 18-39 years CPT Code 99396: Periodic Preventive Medicine Established Patient 40-64 years CPT Code 99397: Periodic Preventive Medicine Established Patient 65 years & older

Adult annual preventive care visits New patient CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older

Established patient CPT Code 99395: Periodic Preventive Medicine Established Patient 18-39 years CPT Code 99396: Periodic Preventive Medicine Established Patient 40-64 years CPT Code 99397: Periodic Preventive Medicine Established Patient 65 years & older Adolescent annual preventive care visits

New patient CPT Code 99382: Initial Preventive Medicine New Patient age 1-4 years CPT Code 99383: Initial Preventive Medicine New Patient age 5-11 years CPT Code 99384: Initial Preventive Medicine New Patient age 12-17 years

DIAGNOSIS CODES FOR FULL, PARTIAL OR INTERPERIODIC SCREENS

Providers must use V20.2 as the primary diagnosis on claims for HCY screening services. There are two exceptions. CPT codes 99381EP and 99391EP must be billed with diagnosis code V20.2, V20.31 or V20.32. CPT codes 99385 and 99395 must be billed with diagnosis code V25.01-V25.9, V70.0 or V72.31.

FULL SCREENING PROCEDURE CODES (New Patient) Procedure Code (Use Age Appropriate Code)

Modifier 2 Fee 99381* EP $60.00 99382* EP $60.00 99383* EP $60.00 99384* EP $60.00 99385* EP $60.00

PARTIAL SCREENING

Different providers may provide segments of the full medical screen. The purpose of this is to increase the access to care for all children and to allow providers reimbursement for those separate screens. When expanded HCY services are accessed through a partial or interperiodic screen, it is the responsibility of the provider completing the partial screening service to have a referral source to refer the child for the remaining components of a full screening service.

An unclothed physical and history screen (CPT codes 9938152EP-9938552EP and 9939152EP-9939552EP) includes the first five sections of the age appropriate screening guide including:

• Interval history;

• Unclothed physical exam;

• Anticipatory guidance;

• Laboratory/Immunizations; and

• Age appropriate lead screening. Federal regulations require a mandatory blood lead testing by either capillary or venous method at 12 months and

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Coding for Pediatrics 2024 : A Manual for Pediatric Documentation and Payment By: Committee on Coding and Nomenclature, American Academy of Pediatrics Edited by: Linda D. Parsi, MD, MBA, CPEDC, FAAP https://doi.org/10.1542/9781610026864 ISBN (print): 978-1-61002-685-7 ISBN (electronic): 978-1-61002-686-4 Publisher: American Academy of Pediatrics

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• Front Matter Open the PDF Link PDF for Front Matter in another window
• 1: The Basics of Coding Doi: https://doi.org/10.1542/9781610026864-ch1 Open the PDF Link PDF for 1: The Basics of Coding in another window
• 2: Coding Edits and Modifiers Doi: https://doi.org/10.1542/9781610026864-ch2 Open the PDF Link PDF for 2: Coding Edits and Modifiers in another window
• 3: Coding to Demonstrate Quality and Value Doi: https://doi.org/10.1542/9781610026864-ch3 Open the PDF Link PDF for 3: Coding to Demonstrate Quality and Value in another window
• 4: The Business of Medicine: Working with Current and Emerging Payment Systems Doi: https://doi.org/10.1542/9781610026864-ch4 Open the PDF Link PDF for 4: The Business of Medicine: Working with Current and Emerging Payment Systems in another window
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• 6: Evaluation and Management Documentation Guidelines Doi: https://doi.org/10.1542/9781610026864-ch6 Open the PDF Link PDF for 6: Evaluation and Management Documentation Guidelines in another window
• 7: Non-preventive Evaluation and Management Services in Outpatient Settings Doi: https://doi.org/10.1542/9781610026864-ch7 Open the PDF Link PDF for 7: Non-preventive Evaluation and Management Services in Outpatient Settings in another window
• 8: Preventive Services Doi: https://doi.org/10.1542/9781610026864-ch8 Open the PDF Link PDF for 8: Preventive Services in another window
• 9: Telephone and Online Digital Evaluation and Management Services Doi: https://doi.org/10.1542/9781610026864-ch9 Open the PDF Link PDF for 9: Telephone and Online Digital Evaluation and Management Services in another window
• 10: Indirect Management of Chronic and Complex Conditions Doi: https://doi.org/10.1542/9781610026864-ch10 Open the PDF Link PDF for 10: Indirect Management of Chronic and Complex Conditions in another window
• 11: Mental and Behavioral Health Services Doi: https://doi.org/10.1542/9781610026864-ch11 Open the PDF Link PDF for 11: Mental and Behavioral Health Services in another window
• 12: Common Testing and Therapeutic Services Doi: https://doi.org/10.1542/9781610026864-ch12 Open the PDF Link PDF for 12: Common Testing and Therapeutic Services in another window
• 13: Qualified Nonphysician Health Care Professional Services Doi: https://doi.org/10.1542/9781610026864-ch13 Open the PDF Link PDF for 13: Qualified Nonphysician Health Care Professional Services in another window
• 14: Surgery, Infusion, and Sedation in the Outpatient Setting Doi: https://doi.org/10.1542/9781610026864-ch14 Open the PDF Link PDF for 14: Surgery, Infusion, and Sedation in the Outpatient Setting in another window
• 15: Emergency Department Services Doi: https://doi.org/10.1542/9781610026864-ch15 Open the PDF Link PDF for 15: Emergency Department Services in another window
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• 19: Common Surgical Procedures and Sedation in Facility Settings Doi: https://doi.org/10.1542/9781610026864-ch19 Open the PDF Link PDF for 19: Common Surgical Procedures and Sedation in Facility Settings in another window
• 20: Telemedicine Services Doi: https://doi.org/10.1542/9781610026864-ch20 Open the PDF Link PDF for 20: Telemedicine Services in another window
• 21: Remote Data Collection and Monitoring Services Doi: https://doi.org/10.1542/9781610026864-ch21 Open the PDF Link PDF for 21: Remote Data Collection and Monitoring Services in another window
• Appendix I: Quick Reference to 2024 ICD-10-CM Pediatric Code Changes Doi: https://doi.org/10.1542/9781610026864-appi Open the PDF Link PDF for Appendix I: Quick Reference to 2024 <em>ICD-10-CM</em> Pediatric Code Changes in another window
• Appendix II: Vaccine Products: Commonly Administered Pediatric Vaccines Doi: https://doi.org/10.1542/9781610026864-appii Open the PDF Link PDF for Appendix II: Vaccine Products: Commonly Administered Pediatric Vaccines in another window
• Appendix III: Test Your Knowledge! Answer Key Doi: https://doi.org/10.1542/9781610026864-appiii Open the PDF Link PDF for Appendix III: Test Your Knowledge! Answer Key in another window
• Subject Index Doi: https://doi.org/10.1542/9781610026864-subjectindex Open the PDF Link PDF for Subject Index in another window
• Code Index Doi: https://doi.org/10.1542/9781610026864-codeindex Open the PDF Link PDF for Code Index in another window

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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)

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