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

Get insights on CPT code 99391 for infant preventive visits, including documentation, billing rules, and more.

What is a preventive visit for infants?

99391 CPT code is designated for a periodic comprehensive preventive medicine reevaluation and management of an established patient who is an infant under 1 year of age. This code encompasses a well-child visit that includes an age- and gender-appropriate history, physical examination, counseling/anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures.

These visits are typically scheduled at 1, 2, 4, 6, 9, and 12 months of age, aligning with the American Academy of Pediatrics (AAP) periodicity schedule.

Key components of preventive visit for infants

Comprehensive history: This should include reviewing the infant's birth history, feeding patterns, sleep habits, and developmental milestones.
Physical examination: It involves the assessment of growth parameters (weight, length, head circumference), vital signs, and head-to-toe examination to detect any abnormalities.
Developmental surveillance: This includes monitoring of the infant's developmental progress, with formal screening at recommended intervals.
Anticipatory guidance: This should provide patients or guardians with information on what to expect in the child's development, safety precautions, nutrition, and behavior
Immunization review: This includes evaluation and administration of age-appropriate vaccines as per the recommended immunization schedule.

These preventive visits are crucial for early detection of potential health issues and for guiding parents in promoting their child's health and development.

Documentation requirements

When billing CPT code 99391 for a routine child health examination in an established patient under 1 year of age, documentation must meet the requirements outlined in preventive medicine services coding standards. This includes a detailed record of the new patient infant's age-appropriate history and comprehensive exam findings.

Clear documentation supports the preventive nature of the service and ensures compliance with payer guidelines. These are the requirements:

Age-appropriate history and developmental milestones: Document a comprehensive history including birth details, feeding habits, sleep patterns, and developmental milestones. This forms part of the age and gender appropriate history examination counseling required for a comprehensive preventive medicine reevaluation.
Physical examination (growth, head circumference, reflexes): Record all findings from full physical examination, including growth metrics like weight and length, age-appropriate reflexes, and general health screening. These are integral to the periodic comprehensive preventive medicine evaluation and management service.
Immunization reviewed or given: Include a review of the immunization status, vaccines administered (if any), and any ordering of laboratory diagnostic procedures necessary for preventive service delivery
Parental counseling anticipatory guidance: Document any anticipatory guidance, such as prevention, nutrition, and behavior. Any risk factor reduction interventions or counseling provided to the parent or guardian during the encounter for routine child health examination should also be noted.

Proper documentation supports compliance with CPT coding guidelines, ensures alignment with medicaid services policies, and justifies the preventive nature of the visit for reimbursement purposes.

Billing guidelines

CPT code 99391 reports a periodic comprehensive preventive medicine reevaluation for an established patient, an infant younger than 1 year. The billing guidance below is accurate, but can be expanded slightly for clarity and keyword inclusion:

Report 99391 CPT code once per preventive visit for an established infant patient. This code reflects a routine child health examination that includes age-appropriate history, examination, counseling, and risk factor assessment, regardless of whether the findings are normal or abnormal.
If vaccines are administered, report them separately using the appropriate vaccine product and administration CPT codes alongside 99391. This aligns with how providers describe preventive medicine services per CPT reporting guidelines.
Do not use 99391 for problem-oriented services. If a sick visit occurs during the same encounter and meets the requirements of a separate evaluation and management (E/M) service, use the appropriate problem-oriented E/M code in addition to 99391, and append modifier -25 to the E/M code to show that it was significantly and separately identifiable.
Refer to resources such as CPR's Coding Corner and CPT Assistant for updates and further clarification on coding compliance, especially when dealing with examination without abnormal findings vs. examination with abnormal findings in early childhood (age 1 and under).

This ensures accurate billing and reimbursement while supporting documentation that reflects the full scope of preventive medicine services.

Frequently asked questions

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.