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Changes in Medicaid, the Children’s Health Insurance Program (CHIP) and new rules governing employer-sponsored and marketplace insurance plans have improved access to necessary health care for children and young adults over the years. Preventative care protects children against different types of diseases and infections, and allows physicians to monitor and evaluate their physical and mental well-being as they grow and develop. As physicians strive to provide proper preventative care, they can rely on outsourced medical billing and coding services for submitting accurate claims to minimize denials and payment delays, and to indicate that well-care was provided so that quality of care goals can be demonstrated through claims data. Private insurance and Medicaid coverage is available for all age- and gender-appropriate Preventive Medicine visits (Wellness Visits) including all routine immunizations.

The preventive coding guidelines and reporting recommendations of the American Academy of Pediatrics (AAP) are as follows:

Preventive Medicine Service Codes

Preventive medicine service codes are assigned based on whether the patient qualifies as new or established and the patient’s age.

New Patients

For a new patient, initial comprehensive preventive medicine E/M includes:

–    age- and gender-appropriate history
–    physical examination
–    counseling
–    anticipatory guidance, or risk factor reduction interventions
–    ordering of laboratory or diagnostic procedures

The relevant CPT and ICD-10 codes for preventive services for new patients are:

  • CPT code 99381 – Infant younger than 1 yearICD-10 codes:Z00.110 Health supervision for newborn under 8 days old orZ00.111 Health supervision for newborn 8 to 28 days old orZ00.121 Routine child health exam with abnormal findings or

    Z00.129 Routine child health exam without abnormal findings

  • CPT codes:
    99382 Early childhood (age 1–4 years)
    99383 Late childhood (age 5–11 years)
    99384 Adolescent (age 12–17 years)
    ICD-10 codes:Z00.121 and Z00.129
  • CPT code 99385 – 18 years or older
    ICD codes:
    Z00.00 General adult medical exam without abnormal findings
    Z00.01 General adult medical exam with abnormal findings

Established Patients

Periodic comprehensive preventive medicine reevaluation and management includes services and procedures similar to new patients.

  • CPT 99391 Infant (younger than 1 year)ICD-10 codes:Z00.110 Health supervision for newborn under 8 days old orZ00.111 Health supervision for newborn 8 to 28 days old orZ00.121 Routine child health exam with abnormal findings or

    Z00.129 Routine child health exam without abnormal findings

  • CPT 99392 Early childhood (age 1–4 years)ICD-10 codes: Z00.121 Z00.129
  • CPT 99393 Late childhood (age 5–11 years)
  • CPT 99394 Adolescent (age 12–17 years)
  • CPT 99395 18 years or olderICD-10 codes:Z00.00 General adult medical exam without abnormal findings andZ00.01 General adult medical exam with abnormal findings

Points to Note:

  • As preventive medicine service codes are not time-based, time spent during the visit is not relevant in the selection of the appropriate code.
  • The appropriate office or other outpatient service code (99201–99215) should be reported in addition to the preventive medicine service code if: an illness or abnormality is encountered, or a pre existing problem is addressed when performing the preventive medicine service, and if the illness, abnormality, or problem is significant enough to require additional work to perform the key components of a problem-oriented evaluation and management (E/M) service (history, physical examination, medical decision-making, or a combination of these).
  • Modifier 25 should be added on to the office or other outpatient service 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
  • Do not report an insignificant or trivial illness, abnormality, or problem encountered in the process of performing the preventive medicine service that does not require additional work and performance of the key components of a problem-oriented E/M service.
  • Report the following separately from the preventive medicine service code: immunizations and ancillary studies involving laboratory, radiology, or other procedures, or screening tests (e.g., vision, developmental, and hearing screening) identified with a specific CPT code.

Other Commonly Reported ICD-10 Codes for Preventive Services

Encounter and Examination Codes

Z02.0 Examination for admission to educational institution
Z02.4 Examination for driving license
Z02.5 Examination for participation in sport
Z01.00 Examination of eyes and vision without abnormal findings
Z01.01 … with abnormal findings
Z01.110 Hearing examination following failed hearing screening
Z01.10 Encounter for examination of ears without abnormal findings
Z01.118 … with other abnormal findings
Z23 Immunizations – This is the only code in ICD-10-CM for vaccines, and has to be linked to both the product and administration CPT codes
Z29.3 – Encounter for prophylactic fluoride administration

Screening Codes

A screening code is not necessary if the screening is inherent to a routine examination

Z11.1 Respiratory tuberculosis
Z11.3 Infections with a predominantly sexual mode of transmission (excludes HPV and HIV)
Z12.4 Encounter for screening for malignant
Z12.79 Malignant neoplasm of other genitourinary
Z12.89 Malignant neoplasms of other sites examination
Z13.29 Other suspected endocrine disorder
Z13.1 Diabetes mellitus
Z13.228 Other metabolic disorders (e.g., inborn)
Z13.220 Lipid disorders
Z13.21 Nutritional disorder
Z13.228 Other metabolic disorder
Z13.29 Other suspected endocrine disorder examination
Z13.0 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (e.g., anemia, sickle cell)
Z13.89 Other disorders (e.g., depression)
Z13.4- Developmental disorders in childhood (excludes routine screening (e.g., autism)
Z13.88 Disorder due to exposure to contaminants (e.g., lead)

Use of ICD-10 Codes When Immunizations Are Not Administered

Immunizations may not be administered during routine preventive medicine services if parents refuse vaccines or defer them, a patient may be ill at the time and it is counteractive to administer, or the patient may already have had the disease or be immune.

However, non-administration has to be reported as part of the ICD-10 for tracking purposes and quality measures. The ICD-10 codes to report when a vaccine is not given due to a certain condition are:

Z28.01 Acute illness
Z28.02 Chronic illness or condition
Z28.03 Immunocompromised state
Z28.04 Allergy to vaccine or component
Z28.1 Religious reasons
Z28.20 Unspecified reason
Z28.21 Patient refusal
Z28.81 Patient has disease being vaccinated against
Z28.82 Caregiver refusal
Z28.89 Other reason

There are several other codes relevant to pediatric preventive medicine services. Moreover, certain insurance companies may require that HCPCS codes be reported in place of or as a supplement to CPT codes. Medical billing and coding outsourcing is a viable option for error-free reporting of pediatric preventative encounters in accordance with regulatory rules and payer requirements and ensure optimal reimbursement.