CPT® code 99381 is used to report an initial comprehensive preventive medicine evaluation and management (E/M) visit for a new patient from birth to 1 year of age. This visit is typically performed in pediatric, family medicine, and integrative wellness clinics.
What is CPT Code 99381?
CPT 99381 represents the first well-baby visit, which involves a thorough history, physical examination, and counseling aimed at promoting the health and development of infants.
This comprehensive visit typically includes:
- Detailed assessment of prenatal and birth history
- Evaluation of growth parameters such as weight, length, and head circumference
- Screening for congenital conditions and developmental milestones
- Review of nutrition, feeding patterns, and sleep habits
- Immunization counseling and scheduling
- Guidance on safety, injury prevention, and parental education
The purpose is to establish a foundation for healthy growth and early detection of potential health concerns.
When to Use CPT Code 99381
Use CPT 99381 for a new patient preventive visit for infants aged 0 to 12 months. This visit is distinct from problem-focused visits and is billed for new patients who have not previously been seen by the provider or practice.
Documentation should include:
- Comprehensive infant medical and family history
- Detailed physical exam findings
- Immunization records and administration, if applicable
- Counseling provided to caregivers on infant care and development
- Any screening tests performed and results
Coding Considerations
- CPT 99381 is reserved for new patients; use CPT 99391 for established patients in this age group.
- Time is not the primary factor in billing; the focus is on the thoroughness of history, exam, and counseling.
- If additional services such as treatment for illness or injury are provided, report separately using appropriate E/M codes.
- Use the appropriate ICD-10 Z codes to indicate preventive care (e.g., Z00.110 for newborn exam).
CPT 99381 and Early Childhood Preventive Care
The initial preventive visit is critical for supporting infant health, educating caregivers, and setting up a medical home. Insurers typically cover this service as part of routine well-child care benefits.
Proper documentation is essential to demonstrate the comprehensive nature of the evaluation and the preventive counseling provided.
Simplify Infant Wellness Visits with OptiMantra
Pediatric and family practices providing infant preventive care face the challenge of thorough documentation and tracking of immunizations and developmental milestones. OptiMantra supports these needs by offering:
- Customizable templates for age-specific well-child visits for newborn care
- Integrated scheduling and inventory management
- Customizable documentation prompts for counseling and screening
- Effortless generation of CPT-coded superbills aligned with payer requirements
With OptiMantra, clinicians can efficiently deliver comprehensive, compliant infant preventive visits—helping families get the best start while maximizing practice revenue.
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