The American Academy of Pediatrics (AAP)/Bright Futures recommends well-child visits as a strategy for pediatricians and parents to support the needs of children. Outsourcing medical coding can help ensure accurate capture of services provided to maximize reimbursement opportunities. In addition to being up-to-date with the latest codes, coders with pediatric clinical experience are familiar with the different clinical indicators that present in children and are also knowledgeable about payer’s reporting requirements which is important to prevent denials.
Pediatric Preventive Care CPT Codes and Reporting Guidelines
The AAP’s recommendations for children’s preventive healthcare include a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence. The 2018 CPT codes for preventive pediatric care and reporting guidelines are as follows:
Pediatric preventive evaluation and management (E/M): A November 2017 AAPC report says that it is important for medical coding service providers to know which preventive services are included in the pediatric preventive evaluation and management (E/M) services and which are separately reported.
- Services not separately reported: Pediatric preventive evaluation and management (E/M) services (CPT 99381-99385 and 99391-99395)include an age- and gender-appropriate history and assessment. These should not be reported separately unless they are related to a significant, problem-oriented E/M service or required by payer policy. When provided at the same encounter, preventive E/M service includes anticipatory guidance and counseling for risk factor reduction (99401-99404, 99411, and 99412) as well as discussions on diet, exercise, home and travel safety, and substance use avoidance.
- Services that are separately reportable: CPT instructs that the following services are not included in pediatric preventive E/M services:
- Immunization administration – CPT 90460-90461 or 90471-90474:
- Vision screening: annual quantitative estimate based on graduated visual stimuli such as the Snellen chart at ages 4-7 years (age 3 in cooperative children) and then biennially through age 12, and at age 15 – CPT 99173, 99174, 99177, 0333T.
- Hearing screening: annually at ages 4-6 years, then at ages 8 and 10, and by audiometry with high frequencies once each between ages 11-14, 15-17, and 18-21 (92551 Screening test, pure tone, air only, 92583 Select picture audiometry).
- Structured developmental screening at ages 9 months, 18 months, and 24 or 30 months (96110 Developmental screening) with inclusion of separate autism screening at 18 and 24 months (96110); may occur earlier if risks are detected through surveillance.
- Tobacco, alcohol, or drug use assessment performed at ages 11-21, if the risk assessment is positive (96160 Administration of patient health risk assessment instrument for the benefit of the patient, with scoring and documentation, per standardized instrument or if brief intervention, 99406-99409)
- Maternal depression screening at 1, 2, 4, and 6 months (96161 Administration of caregiver-focused health risk assessment instrument for the benefit of the patient, with scoring and documentation, per standardized instrument
- Depression screening (patient) with a validated screening instrument – annually at ages 12-21 years (96127 Brief emotional/behavioural assessment with scoring and documentation, per standardized instrument.
- Preventive laboratory testing and/or blood drawing, when performed; some payers require modifier 33 Preventive service for services, such as laboratory testing, to identify the preventive purpose of the testing (e.g., depression screening in an adolescent, 96127-33).
- Application of fluoride varnish (99188 Application of topical fluoride varnish by a physician or other qualified health care professional).
- Any significant, separately identifiable E/M service addressing a complaint or problem found and reported with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended to the E/M code.
- New or established patient: Preventive medicine service codes depend on whether the patient is new or established. A new patient is defined as one who has not received any professional face-to-face services rendered by physicians and other qualified health care professionals who may report E/M services and reported by a specific CPT ® code(s) from a physician/other qualified health care professional, or another physician/other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.
- Age: The preventive medicine service code is selected based on age.
- For new patients:
- 99381 Infant (younger than 1 year)
- 99382 Early childhood (age 1–4 years)
- 99383 Late childhood (age 5–11 years)
- 99384 Adolescent (age 12–17 years) 99385 18 years or older
- For established patients:
- 99391 Infant (younger than 1 year)
- 99392 Early childhood (age 1–4 years)
- 99393 Late childhood (age 5–11 years)
- 99394 Adolescent (age 12–17 years)
- 99395 18 years or older
- Time: Preventive medicine service codes are not time-based, meaning that time spent during the visit is not relevant in choice of the preventive medicine services code. The service may be billed based on time only if the time spent in counseling and/or coordination of care is more than half the total time spent during the encounter.
- Counseling: Counseling codes (99401–99404) are distinct from other E/M services that may be reported separately when performed. If counseling and/or risk factor reduction services are provided on dates when no preventive medicine E/M service represented by codes 99381-99385 or 99391-99395 is provided, CPT codes 99401-99404 or 99411-99412 should be reported based on the time of service. The CPT codes to report preventive medicine counselling are:
- 99401 Preventive medicine counseling or risk factor reduction intervention(s) provided to an individual; approximately 15 minutes
- 99402 approximately 30 minutes 99403 approximately 45 minutes
- 99404 approximately 60 minutes
- 99411 Preventive medicine counseling or risk factor reduction intervention(s) provided to individuals in a group setting; approximately 30 minutes
- 99412 approximately 60 minutes
- Immunization Administration (IA)
CPT codes 90460-90461
Payment for vaccine administration includes both the vaccine product and administration. The 2018 pediatric immunization administration codes are:
90460 Immunization administration (IA) 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 or toxoid component administered
90460-90461 – Points to note:
– CPT codes 90460 and 90461 are reported regardless of route of administration.
– 90460 is used to report the first or only component in a single vaccine given during an encounter. 90460 can be reported more than once during a single office encounter.
– 90461 is reported in addition to 90460 if more than 1 component is contained within a single vaccine administered.
– Codes 90460– 90461 are reported only when both of the following requirements are met:
- The patient must be 18 years or younger.
- The physician or other qualified health care professional must perform face-to-face vaccine counseling associated with the administration.If both of these requirements are not met, a non–age-specific IA code (90471–90474) should be reported.
- CPT codes 90471-90474
All immunization administrations (i.e., to patient 19 years and older or provided without physician/QHP counseling) are reported with codes 90471-90474. Only one initial immunization code (90471, 90473) is reported on a single date of service.
90471 IA (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)
+90472 each additional vaccine (single or combination vaccine/toxoid) (List separately to code for primary procedure.)
90473 IA (includes intranasal or oral administration); one vaccine (single or combination vaccine/toxoid)
+90474 each additional vaccine (single or combination vaccine/toxoid) (List separately to code for primary procedure.)
90471-90474 – Points to note
– Codes 90471 and 90473 are used to code for the first immunization given during a single office visit.
– Codes 90472 and 90474 are add-on codes to 90460, 90471, and 90473, that is, the provider should report 90472 or 90474 in addition to 90460, 90471, or 90473 if more than 1 vaccine is administered during a visit.
Modifier 25 should be appended to the E/M service to indicate a significant and separately identifiable service. It is necessary to adhere to state-specific coding requirements for immunizations using vaccines supplied through the Vaccines for Children Program. All pediatric preventive CPT codes should be supported by the corresponding ICD-10 codes that support the medical necessity of the service provided. With all these challenges, the services of clinical documentation specialists (CDSs) and medical coding companies specialized in pediatric medical billing and coding would be of great assistance to report pediatric preventive care correctly based on payers’ specific rules.