Coding for Well Child Visits

January 30th, 2015 - Betsy Nicoletti

Pediatricians perform well baby and well child visits everyday and it is no mystery how to code for these services. Preventive medicine services are billed based on the age of the patient and whether or not the patient is a new or an established patient to the practice. The definition of a new or an established patient is the same if for office visits codes and the preventive medicine services. A new patient is a patient who has not been seen by that physician or by another physician of the same specialty in the same group within the past three years. Practically speaking, this means that if someone in the group sees the patient in the hospital and provides newborn care, the first visit to the pediatrician's office is an established patient visit. A new patient preventive medicine service would be a service provided to a patient who has never been seen by that physician or by one of that physician's partners in any location in the past three years.

What services are included in preventive medicine services? The CPT book states it is an age and gender appropriate history and exam, along with anticipatory guidance and risk factor reduction. The CPT book does not define the level of history and exam required in any more detail, except to say that it is not the "comprehensive history and exam seen for high level evaluation and management services". The CPT book suggests contacting specialty societies for further definitions.

Well visits also include administration of immunizations and referral for/or provision of screening tests. These services, administration of immunization, immunization serum if purchased by the practice, and screening tests may be billed separately.

How does a physician bill for a camp or sports physical? In a perfect world, a patient would need their sports physical form filled out at the same visit for their annual well visit. Insurance companies typically allow multiple preventive medicine visits in the first year of life and thereafter only pay for one preventive medicine service annually. So what does the physician do if a patients presents for a sports physical at another time than their well visit? Bill for the service using an office visit code in the 99212 --99215 series of codes depending on the level of service. Some insurance companies will not pay for a second E/M service with a “well exam” diagnosis code. However, this is the appropriate way to bill for these services.

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