Billing Guidelines for Well-Child Visits
Well-Child Visits: Services are identified using the CPT Preventive Medicine Services Codes. In some cases, one or two modifiers are required to uniquely identify the service provided.
Each preventive medicine service code billed will be required to have a referral code with the exception of Family Planning services (99383-99385 with modifier FP, or 99393-99395 with modifier FP).
Family Planning services do not require a well-child referral code.
- 99381: New Patient Under One Year
- 99382: New Patient Ages 1-4 years
- 99383: New Patient Ages 5-11 Years
- 99384: New Patient Ages 12-17 Years
- 99385 EP: New Patient Ages 18-20 Years
- 99391: Established Patient Under One Year
- 99392: Established Patient Ages 1-4 years
- 99393: Established Patient Ages 5-11 Years
- 99394: Established Patient Ages 12-17 Years
- 99395 EP: Established Patient Ages 18-20 Years
- EP: used with procedure code 99385 and 99395 to identify children 18 through 20 years of age
- FP: used with procedure code 99383-99385 or 99393-99395 when the appropriate diagnosis is billed for Family Planning services
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) referral codes
Providers who submit paper claims must complete field 24H (EPSDT Family Plan) on the CMS1500 claim form.
- AV: Available-not used (recipient refused referral)
- NU: Not used (no EPSDT recipient referral given)
- S2: Under treatment (recipient currently under treatment for referred diagnostic or corrective health problem)
- ST: New service requested (recipient referred to another provider for diagnostic or corrective treatment or scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service, not including dental referrals)
Providers who bill electronically using the 837P format must select the appropriate response for ASC X12N 837: Loop 2300 element CRC02 – "Was an EPSDT referral given to the patient? (Yes or No)" and provide the appropriate condition indicator in element CRC03 of the electronic claims file. Providers should also submit a value of “Y” in Loop 2400 segment SV111.