Services included in a well-child visit
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)
- Anxiety screening (recommended for ages 8-18 years)
- Depression screening and behavioral assessments (at your discretion for children of all ages)
Well-child visit billing
Follow these guidelines to avoid HEDIS® record audits for well-child visits.
Documenting well-child visit during a sick visit
- 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.
Ages 0-30 months
- Newborn visit 3-5 days post discharge
- AT 2, 4, 6, 9, 12, 15, 18, 24 and 30 months (at least 6 visits in the first 15 months)
- CPT codes 99381, 99382, 99391, 99392, 99461
Ages 3-6 years
- 1 visit per year
- CPT codes 99382, 99383, 99392, 99393
Ages 7-18 years
- 1 visit per year
- CPT codes 99383, 99384, 99385, 99393, 99394, 99395