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 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
OVERVIEW
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.
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
NCCI Edit
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.
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 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
OVERVIEW
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.
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
NCCI Edit
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.