How To Use CPT Code 99381

CPT 99381 is a code for initial comprehensive preventive medicine evaluation and management of an infant under 1 year of age. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99381.

1. What is CPT 99381?

CPT 99381 is a code used to report initial comprehensive preventive medicine evaluation and management services for an infant who is a new patient and is less than one year old. This code is used for well-baby visits, which are preventive in nature and aim to ensure the healthy growth and development of the infant. The services provided under this code include age and gender-appropriate history, examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.

2. 99381 CPT code description

The official description of CPT code 99381 is: “Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)”.

3. Procedure

The 99381 procedure involves the following steps:

  1. Taking a comprehensive age and gender-appropriate history of the infant.
  2. Performing a comprehensive examination of the infant, considering their age and gender.
  3. Providing counseling and anticipatory guidance to the caregiver regarding the infant’s growth, development, and preventive care.
  4. Identifying and addressing risk factors for the infant’s health and well-being.
  5. Ordering appropriate laboratory and diagnostic tests to assess the infant’s health status and identify any potential issues.

4. Qualifying circumstances

An infant is eligible to receive CPT code 99381 services if they meet the following criteria:

  • The infant is a new patient, meaning they have not previously received any professional services from the provider or another provider of the same specialty within the same practice.
  • The infant is younger than 1 year of age.
  • The visit is for preventive care and not for the evaluation or management of a specific health problem or concern.

5. When to use CPT code 99381

It is appropriate to bill the 99381 CPT code when a provider performs an initial comprehensive preventive medicine evaluation and management service for an infant who is a new patient and is less than one year old. This code should be used for well-baby visits that focus on preventive care, including age and gender-appropriate history, examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.

6. Documentation requirements

To support a claim for CPT 99381, the following information needs to be documented:

  • A comprehensive age and gender-appropriate history of the infant, including any relevant family and social history.
  • A detailed account of the comprehensive examination performed, including any pertinent findings.
  • A summary of the counseling and anticipatory guidance provided to the caregiver, as well as any risk factor reduction interventions discussed or implemented.
  • A list of any laboratory or diagnostic tests ordered, along with their rationale and any results obtained.
  • Confirmation that the infant is a new patient and is younger than 1 year of age.

7. Billing guidelines

When billing for CPT code 99381, keep in mind the following guidelines and tips:

  • Ensure that the infant meets the eligibility criteria for this code, including being a new patient and younger than 1 year of age.
  • Document all required information to support the claim, as outlined in the documentation requirements section.
  • If a distinct evaluation and management service for a specific problem is performed during the same encounter, it may be reported separately using the appropriate E/M code.
  • Remember that laboratory/diagnostic tests and immunization services provided during the visit may be reported separately.

8. Historical information

CPT 99381 was added to the Current Procedural Terminology system on January 1, 1992. There have been several updates to the code description since then, with the most recent change occurring on January 1, 2009.

9. Similar codes to CPT 99381

Five similar codes to CPT 99381 and how they differentiate are:

  • CPT 99382: This code is used for initial comprehensive preventive medicine evaluation and management services for a new patient aged 1 through 4 years.
  • CPT 99383: This code is used for initial comprehensive preventive medicine evaluation and management services for a new patient aged 5 through 11 years.
  • CPT 99384: This code is used for initial comprehensive preventive medicine evaluation and management services for a new patient aged 12 through 17 years.
  • CPT 99385: This code is used for initial comprehensive preventive medicine evaluation and management services for a new patient aged 18 through 39 years.
  • CPT 99386: This code is used for initial comprehensive preventive medicine evaluation and management services for a new patient aged 40 through 64 years.

10. Examples

Here are 10 detailed examples of CPT code 99381 procedures:

  1. A 6-month-old infant is brought in for a well-baby visit, during which the provider takes a comprehensive history, performs a thorough examination, discusses growth and development milestones with the caregiver, and orders routine laboratory tests.
  2. A 3-month-old infant is seen for a well-baby visit, and the provider identifies a potential risk factor for developmental delay, provides counseling and anticipatory guidance to the caregiver, and orders appropriate diagnostic tests.
  3. An 11-month-old infant is brought in for a well-baby visit, and the provider performs a comprehensive examination, discusses immunization schedules with the caregiver, and orders necessary laboratory tests.
  4. A 9-month-old infant is seen for a well-baby visit, during which the provider takes a detailed history, performs a thorough examination, provides counseling on nutrition and sleep habits, and orders routine laboratory tests.
  5. A 4-month-old infant is brought in for a well-baby visit, and the provider identifies a potential risk factor for a health issue, provides counseling and anticipatory guidance to the caregiver, and orders appropriate diagnostic tests.
  6. An 8-month-old infant is seen for a well-baby visit, during which the provider takes a comprehensive history, performs a thorough examination, discusses growth and development milestones with the caregiver, and orders necessary laboratory tests.
  7. A 2-month-old infant is brought in for a well-baby visit, and the provider performs a comprehensive examination, provides counseling on nutrition and sleep habits, and orders routine laboratory tests.
  8. A 7-month-old infant is seen for a well-baby visit, during which the provider takes a detailed history, performs a thorough examination, identifies a potential risk factor for a health issue, and orders appropriate diagnostic tests.
  9. A 5-month-old infant is brought in for a well-baby visit, and the provider performs a comprehensive examination, discusses immunization schedules with the caregiver, provides counseling and anticipatory guidance, and orders necessary laboratory tests.
  10. A 10-month-old infant is seen for a well-baby visit, during which the provider takes a comprehensive history, performs a thorough examination, identifies a potential risk factor for developmental delay, and orders appropriate diagnostic tests.

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