Well-child visit billing
Services included in a well-child visit
Find well-child history and exam forms in the provider forms section of this website. Each well-child visit should document:
- Health and developmental history (physical and mental)
- Physical exam
- Health education and anticipatory guidance
- BMI percentile (counseling for nutrition and physical activity)
Coding
Follow these guidelines to avoid HEDIS® record audits for well-child visits.
- Sick visits – When a sick patient comes in and is due for a well-child visit, document all the components of a well-child visit. They can be reported in addition to the problem-oriented visit.
Documentation must support that both services were provided in their entirety as significant and separately identifiable services. Then report the problem-oriented E&M service with the 25 modifier. This allows us to capture data for the well-child visit and will reimburse for both services.
- Sports physicals – If a child needs a sports physical for school and is due for a well-child visit, complete all the services of a well-child visit. Use appropriate diagnosis codes.
- New patient preventive visits – Complete and document all well-child visit components and report them.
| Age group |
CPT codes |
Diagnosis codes |
| 0-15 months |
99381, 99382, 99391, 99392, 99461 |
V20.1, V70.0, V70.6, V70.8, V70.9 |
| 3-6 years |
99382, 99383, 99392, 99393 |
V20.1, V70.0, V70.6, V70.8, V70.9 |
| 12-21 years |
99384, 99385, 99394, 99395 |
V20.1, V70.0, V70.6, V70.8, V70.9 |
Standards for frequency
- Infants 0-15 months: At least 6 visits in the first 15 months
- Children 3-6 years: 1 visit per year
- Adolescents 12-21 years: 1 visit per year
Incentives
Well-child visits for 0-15 months, 3–6 year olds and 7-12 year olds are PCP Incentive Program (PIP) measures. Go to the PIP program criteria to learn more.
- To find patients needing well-child visits: Use the online Patient Profile tool to sort your patients by missed visits.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
