CPT Code 99391: Periodic Preventive E/M, Established Patient, Infant (Age <1 Year)

Yes, you can report 99391 CPT code and 99212 on the same day if a separate problem-oriented service is provided, such as evaluation of an acute illness. In such cases, append modifier -25 to the E/M code (e.g., 99212) to indicate a significant, separately identifiable service was performed in addition to the preventive medicine evaluation and management. Documentation must support both services.

No, vaccines and their administration are not included in CPT code 99391. You must bill vaccine product codes and administration codes separately. The preventive visit may include a review of immunization history, but services provided, such as injections, are distinct and must be reported using applicable codes based on patient’s age and vaccine schedule.

If a child misses a scheduled preventive visit, bill the periodic comprehensive preventive medicine reevaluation code that corresponds to the child’s age on the date of the visit.