Preventative Visits
For infants and toddlers’ preventative visits are more frequent between birth and 4 years old with a total of 13 wellness visits. These visits include:
- Measurements
- Sensory screening
- Mental, social behaviors
- Behavioral mental health
- Physical examination
- Procedures if necessary
- Anticipatory guidance
- Immunizations
During these visits it is a great time to discuss, child’s development, and safety in the home and at school. It is good to make a list of topics you want to talk about with your child’s pediatrician such as development, behavior, sleep, eating or getting along with other family members.
Beginning, at the age of 4 children will begin receiving yearly preventative visits throughout adolescents, teenage years, into adulthood. These visits should be billed with new or established preventative visit codes which range from 99381-99387 new patients and 99391-99397 established patients.
When vaccines are administered during wellness visits modifiers 25 should be used on the E/M code to represent a separately identifiable visit. Vaccines should be billed with counseling codes if counseling was performed. If counseling was not performed there separate administrative CPT codes to be used. Our next set of CPT codes will represent the types of vaccines administered by listing each code multiple times or use times (x) symbol and indicate number given.
Modifier -51 should not be reported for the vaccines, toxoids when performed with these administration codes (90460-90474).
Example of pediatric wellness visit
A 4-month-old female established patient presents for her checkup. The mother states that the patient drinks 4 oz bottles every 2-3 hours, wakes up once during the middle of the night. No concerns for any developmental delays. Physical exam is normal height and wight within normal limits for her age. Will see her back for a 6-month wellness visit.
The following vaccines are ordered: Pentacel (diphtheria-tetanus-acellular pertussis [DTaP], Haemophilus influenzae type b [Hib], inactivated poliovirus [IPV]), pneumococcal, and rotavirus. The physician counsels the parents on all of them, consent is obtained, and the nurse administers them all.
Assessment and plan:
- 99391 modifier 25 Preventive medicine service, established patient, <1 year diagnosis code Z00.129 Routine child health exam without abnormal findings
- 90698 DTaP-Hib-IPV (Pentacel) product diagnosis code Z23 Encounter for Immunization
- 90670 Pneumococcal product Z23 Encounter for Immunization
- 90680 Rotavirus vaccine, oral use Z23 Encounter for Immunization
- 90460 (×3) Pediatric IA (Pentacel, pneumococcal, rotavirus), first component diagnosis code Z23 Encounter for Immunization
- 90461 (×4) Pediatric IA (Pentacel), each additional component diagnosis code Z23 Encounter for Immunization
Example of Adult Wellness Visit
An 18-year-old female patient presents to the office for her annual checkup and to complete a college physical examination (in college, the patient will be living in a dormitory). The patient has no complaints and is excited to start her first year of college. Will be rooming with a friend from high school. Parents also have no significant concerns currently. The patient is healthy with a routine physical exam and is due for a Tdap booster, meningococcal vaccine, first HPV (9-valent) vaccine, and influenza vaccine. The physician counsels the patient and mother only on the meningococcal and HPV vaccines, and the nurse administers each. The patient is asked to return in 4 to 6 weeks (about one and a half months) for her second HPV vaccine before she leaves for school.
Assessment and plan:
- 99395 modifier 25 Preventive medicine service, established patient, 18 years or older Z00.0 General adult medical exam without abnormal findings and Z02.0 Encounter for examination for admission to the educational institution
- 90734 Meningococcal (MCV4) product Z23 Encounter for Immunization
- 90651 HPV (9-valent) product Z23 Encounter for Immunization
- 90460 (×2) Pediatric IA (meningococcal and HPV), first component Z23 Encounter for Immunization
- 90715 Tdap product Z23 Encounter for Immunization
- 90472 (×2) IA, each additional injection (Tdap) Z23 Encounter for Immunization
- 90686 Influenza virus vaccine, quadrivalent, preservative-free, 0.5 mL dosage Z23 Encounter for Immunization
When a patient is present to the office for a preventative visit, and they are sick, a sick visit can be billed with modifier 25 listed on the wellness visit. The E/M code is selected on MDM or Time. If time is a factor when selecting a code level for the sick visit, remember any time spent on the patient’s wellness visit is not counted.
Conclusion
As you can see, medical coding and billing services is very complex with codes scattered between many ages and services. This is proven with the variety diagnosis and preventative visits code selections.
For assistance with this process, please do not hesitate to reach out to us directly. At Neolytix, we are always ready to assist your practice with medical billing, coding, and revenue cycle management.
