CPT® code 99391 is used to report a periodic comprehensive preventive medicine evaluation and management (E/M) visit for an established patient aged 0 through 1 year. This service is primarily provided in pediatric, family medicine, and integrative wellness settings to monitor infant health and development.
What is CPT Code 99391?
CPT 99391 covers routine well-baby visits aimed at assessing an infant’s growth, development, and overall health. This comprehensive evaluation includes a detailed history, physical examination, and age-appropriate counseling for caregivers.
Typical components of this visit include:
- Reviewing prenatal, birth, and neonatal history
- Measuring growth parameters such as weight, length, and head circumference
- Assessing developmental milestones and neurological status
- Screening for common conditions and potential health risks
- Providing immunization updates and counseling on nutrition, sleep, safety, and parental guidance
These visits are essential for early detection of health issues and fostering healthy development during infancy.
When to Use CPT Code 99391
Use CPT 99391 for periodic preventive visits in established patients aged 0 to 12 months. This code applies to infants who have been seen previously by the provider or practice for similar preventive services.
Documentation should include:
- A comprehensive review of growth and developmental history
- Detailed physical examination findings
- Immunization records and administration details
- Counseling topics discussed with caregivers
- Any screening tests performed and their outcomes
Coding Considerations
- CPT 99391 is reserved for established patients; use CPT 99381 for new patients in this age group.
- Time is not the primary factor; emphasis is on the thoroughness of the preventive visit.
- If illness or injury evaluation is performed alongside the preventive visit, report separately with appropriate E/M codes.
- Use appropriate ICD-10 Z codes to indicate preventive care (e.g., Z00.110 for newborn exam).
CPT 99391 and Infant Preventive Care
Regular preventive visits during the first year of life are critical for monitoring health, guiding caregivers, and ensuring timely immunizations. Insurers generally cover these visits as part of routine pediatric care.
Accurate and thorough documentation supports medical necessity and reimbursement.
Simplify Infant Wellness Visits with OptiMantra
Pediatric and family practices providing infant preventive care often manage complex documentation, immunization schedules, and developmental tracking. OptiMantra supports these needs by offering:
- Customizable templates for age-specific well-child visits for infants
- Immunization management and scheduling tools
- Smart prompts for developmental screening and counseling documentation
- Seamless generation of CPT-coded superbills aligned with payer requirements
With OptiMantra, clinicians can efficiently deliver thorough, compliant infant preventive visits—supporting healthy starts for children and maximizing practice revenue.
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