icd10 for well child visit

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Pediatric Preventive Services: Coding Quick Reference Card 2024

AAP Committee on Coding and Nomenclature (COCN)

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Description

This convenient card features all evaluation and management service codes, as well as other recommended service codes, for well-child visits from birth to 21 years of age.

This 11″ × 11.5″ card is fully updated for 2024 and laminated for extra durability.

• ISBN-13: 978-1-61002-694-9
• Product Code: MA1118
• Publication Date: November 1, 2023
• Format: Forms and Charts
• Trim Size: 11 inches x 8.5 inches
• Publisher: American Academy of Pediatrics
• Availability: In Stock

American Academy of Pediatrics Committee on Coding and Nomenclature (COCN)

The AAP Committee on Coding and Nomenclature (COCN) is responsible for reviewing of all proposed changes to Current Procedural Terminology (CPT) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding structures to determine whether the Academy will endorse the proposal; participates in the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) survey process by validating clinical vignettes, evaluating survey data and deciding on physician work and practice expense relative value units (RVUs) to recommend to the RUC; and serves as a review panel regarding other activities such as identifying Academy positions on the Medicare Resource-Based Relative Value Scale (RBRVS). 

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Family Life

AAP Schedule of Well-Child Care Visits

Parents know who they should go to when their child is sick. But pediatrician visits are just as important for healthy children.

The Bright Futures /American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care, known as the " periodicity schedule ." It is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence.

Schedule of well-child visits

• The first week visit (3 to 5 days old)
• 1 month old
• 2 months old
• 4 months old
• 6 months old
• 9 months old
• 12 months old
• 15 months old
• 18 months old
• 2 years old (24 months)
• 2 ½ years old (30 months)
• 3 years old
• 4 years old
• 5 years old
• 6 years old
• 7 years old
• 8 years old
• 9 years old
• 10 years old
• 11 years old
• 12 years old
• 13 years old
• 14 years old
• 15 years old
• 16 years old
• 17 years old
• 18 years old
• 19 years old
• 20 years old
• 21 years old

The benefits of well-child visits

Prevention . Your child gets scheduled immunizations to prevent illness. You also can ask your pediatrician about nutrition and safety in the home and at school.

Tracking growth & development . See how much your child has grown in the time since your last visit, and talk with your doctor about your child's development. You can discuss your child's milestones, social behaviors and learning.

Raising any concerns . Make a list of topics you want to talk about with your child's pediatrician such as development, behavior, sleep, eating or getting along with other family members. Bring your top three to five questions or concerns with you to talk with your pediatrician at the start of the visit.

Team approach . Regular visits create strong, trustworthy relationships among pediatrician, parent and child. The AAP recommends well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental and social health of a child.

More information

Back to School, Back to Doctor

Recommended Immunization Schedules

Milestones Matter: 10 to Watch for by Age 5

Your Child's Checkups

• Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (periodicity schedule)

Doctor Visits

Make the Most of Your Child’s Visit to the Doctor (Ages 5 to 10 Years)

Take Action

Children ages 5 to 10 years need to go to the doctor or nurse for a “well-child visit” once a year.

A well-child visit is when you take your child to the doctor to make sure they’re healthy and developing normally. This is different from other visits for sickness or injury.

At a well-child visit, the doctor or nurse can help catch any problems early, when they may be easier to treat. You’ll also have a chance to ask any questions you may have about your child’s behavior or development.

Learn what to expect so you can make the most of each visit.

Child Development

How do i know if my child is growing and developing on schedule.

Your child’s doctor or nurse can help you understand how your child is developing and learning to do new things — like read or brush their teeth. These are sometimes called “developmental milestones.”

Developmental milestones for children ages 5 to 10 years include physical, learning, and social skills — things like:

• Developing skills for success in school (like listening, paying attention, reading, and math)
• Taking care of their bodies without help (like bathing, brushing teeth, and getting dressed)
• Learning from mistakes or failures and trying again
• Helping with simple chores
• Following family rules
• Developing friendships and getting along with other children
• Participating in activities like school clubs, sports teams, or music lessons

See a complete list of developmental milestones for kids who are:

• Age 5 years
• Ages 6 to 8 years
• Ages 9 to 11 years

Take these steps to help you and your child get the most out of well-child visits.

Gather important information.

Take any medical records you have to the appointment, including a record of vaccines (shots) your child has received. If your child gets special services at school because of a health condition or disability, bring that paperwork, too.

Make a list of any important changes in your child’s life since the last doctor’s visit, like a:

• New brother or sister
• Separation or divorce — or a parent spending time in jail or prison
• New school or a move to a new neighborhood
• Serious illness or death of a friend or family member

Use this tool to  keep track of your child’s family health history .

Help your child get more involved in doctor visits.

You can help your child get involved by letting them know what to expect. Learn how to prepare your child for a doctor visit .

What about cost?

Under the Affordable Care Act, insurance plans must cover well-child visits. Depending on your insurance plan, you may be able to get well-child visits at no cost to you. Check with your insurance company to find out more.

Your child may also qualify for free or low-cost health insurance through Medicaid or the Children’s Health Insurance Program (CHIP). Learn about coverage options for your family.

If you don’t have insurance, you may still be able to get free or low-cost well-child visits. Find a health center near you and ask about well-child visits.

To learn more, check out these resources:

• Free preventive care for children covered by the Affordable Care Act
• How the Affordable Care Act protects you and your family
• Understanding your health insurance and how to use it [PDF - 698 KB]

Ask Questions

Make a list of questions you want to ask the doctor..

Before the well-child visit, write down 3 to 5 questions you have. This visit is a great time to ask the doctor or nurse any questions about:

• A health condition your child has (like asthma, allergies, or a speech problem)
• Changes in behavior or mood
• Problems in school — with learning or with other children

Here are some important questions to ask:

• Is my child up to date on vaccines?
• How can I make sure my child is getting enough physical activity?
• How can I help my child eat healthy?
• Is my child at a healthy weight?
• How can I teach my child to use the internet safely?
• How can I talk with my child about bullying?
• How can I help my child know what to expect during puberty?

Take a notepad, smartphone, or tablet and write down the answers so you can remember them later.

Ask what to do if your child gets sick.

Make sure you know how to get in touch with a doctor or nurse when the office is closed. Ask how to get hold of the doctor on call, or if there's a nurse information service you can call at night or on the weekend. 

What to Expect

Know what to expect..

During each well-child visit, the doctor or nurse will ask you questions about your child, do a physical exam, and update your child’s medical history. You'll also be able to ask your questions and discuss any problems. 

The doctor or nurse will ask you and your child questions.

The doctor or nurse may ask about:

• Behavior — Does your child have trouble following directions at home or at school?
• Health — Does your child often complain of headaches or other pain?
• Emotions — Is your child often very worried about bad things happening?
• School — Does your child look forward to going to school?
• Activities — What does your child like to do after school and on weekends?
• Eating habits — What does your child eat on a normal day?
• Family — Have there been any changes in your family since your last visit?

They may also ask questions about safety, like:

• Does your child always ride in the back seat of the car?
• Does anyone in your home have a gun? If so, is it unloaded and locked in a place where your child can’t get it?
• Is there a swimming pool or other water around your home?

Your answers to questions like these will help the doctor or nurse make sure your child is healthy, safe, and developing normally.

Physical Exam

The doctor or nurse will also check your child’s body..

To check your child’s body, the doctor or nurse will:

• Measure your child’s height and weight
• Check your child’s blood pressure
• Check your child’s vision and hearing
• Check your child’s body parts (this is called a physical exam)
• Give your child shots they need

Learn more about your child’s health care.

• Find out how to get your child’s vaccines on schedule
• Learn about getting your child’s vision checked

Content last updated May 10, 2023

Reviewer Information

This information on well-child visits was adapted from materials from the Centers for Disease Control and Prevention and the National Institutes of Health.

Reviewed by: Sara Kinsman, M.D., Ph.D. Director, Division of Child, Adolescent, and Family Health Maternal and Child Health Bureau Health Resources and Services Administration

Bethany Miller, M.S.W. Chief, Adolescent Health Branch Maternal and Child Health Bureau Health Resources and Services Administration

Diane Pilkey, R.N., M.P.H. Nursing Consultant, Division of Child, Adolescent, and Family Health Maternal and Child Health Bureau Health Resources and Services Administration

September 2021

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It’s not hard, once you get the hang of it, but the differences from E/M coding can be confusing.

TIMOTHY OWOLABI, MD, CPC, AND ISAC SIMPSON, DO

Fam Pract Manag. 2012;19(4):12-16

Dr. Owolabi is a board-certified family physician and certified professional coder employed by Summit Physician Services, a multispecialty, hospital-owned group practice in Chambersburg, Pa. In addition to managing a busy patient panel, Dr. Owolabi independently offers coding consulting services and speaks and writes on coding topics. Dr. Simpson is a family medicine resident at Phoenix Baptist Hospital Family Medicine Residency in Phoenix, Ariz. Author disclosure: no relevant financial affiliations disclosed.

This is a corrected version of the article previously published.

In our experience, family physicians vary widely in their understanding of preventive care coding. Questions we’ve heard range from “What ICD-9 codes are appropriate with preventive care visits?” all the way down to “Preventive codes? What are preventive codes? I only use evaluation and management [E/M] codes.” No matter what your level of comfort (or discomfort) with coding preventive visits, we hope to offer information you’ll find useful. We will define the documentation components necessary to code preventive visits for patients 18 to 64 years old, review the appropriate ICD-9 and CPT codes and how to properly pair them, and discuss the proper use of modifier 25. We won’t cover the Medicare guidelines for preventive visits or how to code pediatric preventive visits. Coding resources for these visits are listed below.

Components of a preventive visit

Preventive visits, like many procedural services, are bundled services. Unlike documenting problem-oriented E/M office visits (99201–99215), which involves complicated coding guidelines, documenting preventive visits is more straightforward. The following components are needed:

A comprehensive history and physical exam findings;

A description of the status of chronic, stable problems that are not “significant enough to require additional work,” according to CPT;

Notes concerning the management of minor problems that do not require additional work;

Notes concerning age-appropriate counseling, screening labs, and tests;

Orders for vaccines appropriate for age and risk factors.

According to CPT, the comprehensive history that must be obtained as part of a preventive visit has no chief complaint or present illness as its focus. Rather, it requires a “comprehensive system review and comprehensive or interval past, family, and social history as well as a comprehensive assessment/history of pertinent risk factors.” The preventive comprehensive exam differs from a problem-oriented comprehensive exam because its components are based on age and risk factors rather than a presenting problem.

Some have attempted to use modifier 52 to denote reduced services when less than a comprehensive history and exam are performed during a preventive visit. This is inappropriate because modifier 52 applies to procedural services only. Preventive visits that do not satisfy the minimum requirements may be billed with the appropriate E/M office visit code.

When submitting a preventive visit CPT code, it is not appropriate to submit problem-oriented ICD-9 codes. Linking problem-oriented ICD-9 codes with preventive CPT codes may delay payment or result in a denied claim. See “ Acceptable codes for preventive care visits ” for the appropriate ICD-9 codes and the HCPCS and CPT codes with which to pair them.

Coverage of preventive visits varies by insurer, so it is important to be aware of the patient’s health plan. Most plans limit the frequency of the preventive visit to once a year, and not all tests are covered. Fecal occult blood tests, audiometry, Pap smear collection, and vaccines and their administration should be billed separately. Visual acuity testing is not separately reimbursed. Without a new or chronic-disease diagnosis, all labs and other tests ordered during a preventive visit are for screening purposes, and an ICD-9 code for screening should be assigned on the order form and claim.

Another service that has a preventive purpose is the preoperative clearance. Review of the details of this encounter is beyond the scope of this discussion, but it is worth mentioning that many private payers cover the preoperative clearance when billed by primary care physicians using consultation E/M codes (99241-99255).

ACCEPTABLE CODES FOR PREVENTIVE CARE VISITS

Preventive visits and the role of counseling.

Preventive visit codes 99381-99397 include “counseling/anticipatory guidance/risk factor reduction interventions,” according to CPT. However, when such counseling is provided as part of a separate problem-oriented encounter, it may be billed using preventive medicine codes 99401-99409. For example, if you provide significant counseling on smoking cessation during a visit for an ankle sprain, you could bill for the counseling in addition to submitting an E/M office visit code for the problem-oriented service. A synopsis of the counseling should be included in your documentation, and ICD-9 codes for preventive counseling should be paired with your CPT codes (see “ Acceptable codes for preventive counseling services ”). Such a visit requires the use of modifier 25.

ACCEPTABLE CODES FOR PREVENTIVE COUNSELING SERVICES

Modifier 25.

When providing a preventive visit with a problem-oriented E/M service or procedural service on the same day, including modifier 25 in your coding may enable you to be paid for both services. CPT says modifier 25 is appropriate when there is a “significant, separately identifiable evaluation and management service by the same physician on the same day.” Stated another way, if the second service requires enough additional work that it could stand on its own as an office visit, use modifier 25. Modifier 25 should usually be attached to the problem-oriented E/M code. However, if the second service is a procedure, such as removal of a skin lesion performed in conjunction with a preventive visit, the modifier should be attached to the preventive visit code because it is the E/M service.

Having a separate note for the second service can greatly decrease the likelihood of having it inappropriately bundled or denied. Note that no one item of documentation can count toward both services. A problem-oriented E/M service that requires a considerable amount of work and pertinent documentation may absorb so many of the elements that would otherwise count toward the preventive service that you don’t have a comprehensive history and exam for the preventive service. This is one reason some doctors provide two visits in these situations.

Bundling is more likely if the separate service can be considered age-appropriate, such as initiating treatment for acne. However, if a separate E/M note can be written for the problem, the CPT description of modifier 25 and the exclusions listed for the preventive visit CPT codes indicate that the separate service should not be bundled. See “ Appropriate use of modifier 25 during a preventive visit ” for examples of complaints that under some circumstances would be handled as part of a preventive visit, but under different circumstances may require additional work that should be billed separately using modifier 25.

Unfortunately, not all carriers pay for services billed with modifier 25. For example, Aetna did not reimburse at all for modifier 25 until 2006, when it changed its policy as part of a class action settlement with multiple state medical societies. The circumstances in which its use is permitted and the amount of payment for the separate service vary. The lack of consensus on the use of modifier 25 for preventive services places the onus on providers to learn the requirements of each of their payers.

APPROPRIATE USE OF MODIFIER 25 DURING A PREVENTIVE VISIT

Preventive care and productivity.

Discussing the cost-effectiveness of preventive visits for the practice is tricky because of the number of variables to consider. Time spent per preventive visit is a key confounding variable. Others include fee schedule variations between payers, payer mix, productivity variations between physicians, which preventive service is being considered (for patients in the 18–39 age group vs. those in the 40–64 age group or new vs. established), and accuracy of coding, to mention a few.

While the numerous variables make broad generalizations about the immediate cost-effectiveness of preventive visits extremely difficult, careful analysis may lead some practices to conclude that preventive care is beneficial not only for the patient but for the practice as well. As an example, we averaged payment for two visit types from nine actual payers. The visits we considered were a 40-year-old established-patient preventive visit (CPT 99396), minus immunizations and other separate charges, and a level-4, established-patient, problem-oriented visit (CPT 99214). We found the average payment for the preventive visit to be 25 percent higher than for the problem-oriented visit. That is, the preventive visit produces more revenue per unit of time unless the preventive visit takes at least 25 percent longer. Of course, if a preventive visit requires considerably more time than a comparable level-3 or level-4 E/M visit, replacing preventive visits with a larger number of problem-oriented visits could result in more reimbursement overall, at least in theory.

Role of preventive services in our health care system

Some researchers estimate that 75 percent of all health care costs are due directly to preventable chronic conditions, yet as recently as 2004, only 1 percent of money spent on health care in the United States was devoted to prevention. 1 , 2 We don’t wish to spark a debate on whether preventive services directly reduce health care costs, but we speculate that preventive care has the potential to play a more valuable role in our health care system than it does currently. The Centers for Medicare & Medicaid Services did not cover preventive care visits until the institution of the “Welcome to Medicare” visit in 2005. In contrast, many private payers have covered preventive visits for some time. Perhaps this is because they have long recognized that healthy lifestyle choices and routine health surveillance mitigate the risk of chronic disease.

PREVENTIVE VISIT ALGORITHM: PATIENTS AGES 18–64*

Regardless of insurance coverage, patients should at least be offered preventive services even if they must pay out of pocket for them. The “ Preventive visit algorithm ” illustrates how one might approach a preventive visit for a patient in the 18 to 64 age range (except for recommended pregnancy-related services). This schematic is not intended to reflect all the anticipatory guidance or all of the screening that you might recommend for a given patient, but rather includes suggestions based on the strongest evidence-based recommendations from the Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force.

ADDITIONAL RESOURCES FOR CODING PREVENTIVE CARE

Coding for Pediatric Preventive Care 2012 . American Academy of Pediatrics.

What You Need to Know About the Medicare Preventive Services Expansion . FPM . Jan/Feb 2011.

Making Sense of Preventive Medicine Coding . FPM . Apr 2004.

Medicare Preventive Services: Quick Reference . Centers for Medicare & Medicaid Services.

Center for Medicare & Medicaid Services National Health Expenditures and Selected Economic Indicators, Levels and Average Annual Percent Change: Selected Calendar Years 1990–2013 Washington, DC: Center for Medicare & Medicaid Services, Office of the Actuary; 2004.

Institute of Medicine The Future of the Public’s Health in the 21st Century. Washington, DC: National Academy Press; 2002.

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Mother’s health*, transitioning to 10: newborn and infant visits.

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American Academy of Pediatrics; Transitioning to 10: Newborn and Infant Visits. AAP Pediatric Coding Newsletter September 2014; 9 (12): No Pagination Specified. 10.1542/pcco_book125_document003

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Pediatricians will probably be remembering many International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for years to come, well after they are no longer reported. And of these, probably none will be more memorable than the most common reason for visits, the V20 diagnosis codes associated with well-child visits. For International Classification of Diseases, 10th Revision, Clinical Modification ( ICD-10-CM ), the preventive medicine codes have been expanded to include 6 characters beginning with the letter Z (Table 1).

The ICD-10-CM tabular list instructs that codes for an abnor­mal finding at the well-newborn or well-child encounter are also reported. Additional diagnosis codes for abnormal findings may be reported when applicable, even when the problem does not require significant evaluation and management (E/M) in addition to the preventive medicine service provided.

Codes from category P07, disorders of newborn related to short gestation and low birth weight, not elsewhere classified, are for use for a child or an adult who was premature or had a low birth weight as a newborn and this is affecting the patient’s current health status (Table 2).

a Includes the listed conditions, without further specification, as the cause of morbidity or additional care, in newborn; excludes low birth weight due to slow fetal growth and fetal malnutrition ( P05.- ); weight is sequenced before gestational age when both are available.

The following list is a translation of the ICD-9-CM codes for diagnoses included in the American Academy of Pediatrics coding guidance, “Supporting Breastfeeding and Lactation: The Primary Care Pediatrician’s Guide to Getting Paid” ( www2.aap.org/breastfeeding/files/pdf/coding.pdf ). Codes in this list describe many conditions common to the newborn and infant. The list also includes codes for conditions of the mother when associated with lactation. (This list is not all-inclusive; please check an ICD-10-CM coding manual or online reference for additional information when reporting these conditions.)

See also the diagnoses associated with size and maturity included in Table 2.

When the original reason for visit has resolved, report also codes in categories Z86–Z87 to indicate personal history of disease.

*ICD-10-CM O codes represent conditions of the mother in pregnancy, childbirth, and the puerperium and are reported only on claims for care of the mother. E/M of conditions of the mother should be separately documented outside the newborn record and reported only on claims for services to the mother (ie, not the newborn).

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