CPT Code 99381: Initial Preventive Medicine E/M, Infant (Under 1 Year)

What is initial preventive medicine for infants?

CPT code 99381 is used to report an initial preventive medicine evaluation and comprehensive services for a new patient under one year of age. This comprehensive preventive medicine service includes an age and gender-appropriate history and examination, developmental evaluations, anticipatory guidance, and health risk assessment to support early preventive care.

Commonly performed during newborn or well-child visits, this preventive visit allows healthcare providers to monitor developmental milestones, address risk factor reduction interventions, and promote overall health during infancy. While it does not include problem-oriented evaluation and management services or diagnostic procedures, any medically necessary laboratory or diagnostic tests may be reported separately.

CPT 99381 is a foundational part of pediatric healthcare, ensuring comprehensive evaluation and a personalized prevention plan aligned with the patient’s age and developmental stage. Proper use of this CPT code helps avoid claim denials, supports accurate documentation, and allows practices to maximize reimbursement under both Medicaid services and commercial insurance plans.

Documentation requirements

To properly report CPT code 99381, healthcare providers must ensure accurate documentation that reflects the full scope of the comprehensive preventive medicine services provided during the preventive visit for a new patient under 1 year of age. Different codes are used for an established patient.

Documentation should include the following key components:

• Age-appropriate history and physical exam: A detailed comprehensive history and comprehensive exam tailored to the patient’s age, including birth history, feeding patterns, sleep habits, and developmental milestones, in line with coding guidelines from the American Medical Association.
• Developmental screening and risk factor assessment: Screening for potential developmental delays and a health risk assessment to identify risk factor reduction interventions early in the child’s life.
• Screening tests: Document any laboratory or diagnostic procedures performed or ordered, such as hearing or vision screening, head circumference, or growth monitoring, as part of the comprehensive preventive medicine evaluation.
• Anticipatory guidance for caregivers: Include age-relevant anticipatory guidance, such as safety tips, nutrition, sleep routines, and self-care education for parents or guardians.
• Immunization status and coordination: Record the child’s immunization status and any vaccines administered, and ensure the caregiver is informed of follow-up plans.

Billing guidelines

CPT code 99381 is billed once for new infant preventive visits. It covers a comprehensive preventive medicine evaluation and should not be reported with a problem-oriented evaluation and management (E/M) service unless a separate, significant issue is addressed—use Modifier -25.

Vaccines and their administration are billed separately, as are any laboratory tests ordered or diagnostic procedures performed. Clear, accurate documentation ensures proper billing and helps avoid claim denials, especially with Medicaid services and other payers.