Use of CPT code 99391, 99392, 99393, 99394, 99395 and 99396
Periodic comprehensive preventive medicine services are typically well-patient examinations for established patients presenting for reevaluations and/or management of overall health condition with code selection dependent upon the patient’s age. These services include applicable patient history and examination, guidance/recommendation regarding personal risk factors, and any laboratory and/or diagnostic procedures ordered. Clinicians are not required to report minor or self-limiting problems or complaints noted during the course of the preventive examination when those problems do not require any additional work or necessitate performing the key components of a problem oriented E/M service.
CPT code 99391 is reported for infants younger than 1 year of age;
CPT code 99392 is reported for children 1 to 4 years of age;
CPT 99393 is reported for children 5 to 11 years of age;
CPT 99394 is reported for adolescents12 to 17 years of age;
CPT 99395 is reported for adult patients 18 to 39 years of age;
CPT code 99396 is reported for patients 40 to 64 years of age; and
CPT code 99397 for patients 65 years of age and older.
Sample coded report for CPT code 99391
Chief Complaint
Patient presents with
• Well Child
• Other
Itchy gums
SUBJECTIVE:
4 m.o. female brought in by mother for routine check up.
Mom is concerned patient’s gums are itching and bothering her. This has been ongoing for the past 2 weeks. It seems painful and patient is agitated. The area looks red. Mom denies drainage, swelling, bleeding. No new tooth eruptions noted. Mom endorses increased drooling/saliva and patient has been putting her hands in her mouth more.
Home: lives with mother.
Diet: breast 10-15 minutes and formula 4oz every 3 hours Vitamin D: Not supplementing.
Elimination: 5 wet diapers. 2 bowel movements per day, green color.
Sleep: Sleeping on back in crib. Goes to bed 9-10PM and wakes up at 5AM.
Safety: Smokers in home – No. Rear facing car seat – Yes. Lead risk – No. Guns in home – No.
Do the parents have concerns about your child’s behavior – No.
Do the parents have concerns about your child’s development – No.
Have you or anyone spanked your child as form of discipline- No.
Physical Activity Vital Signs
On average, how many days per week does your child get > 30 minutes of tummy time or play throughout the day? Yes, 7 days/week for thirty minutes, 2 times daily.
On average, how many hours per day of recreational screen time (television, movies, phone) does your child get? She watches TV when the parents watch TV.
Food Insecurity Questions
In the last 12 months, did you worry whether food would run out before you got money to buy more? never
In the last 12 months, did the food you bought not last and you didn’t have the money to get more? never
Do you receive SNAP benefits? not evaluated
Diaper Insecurity Questions
Do you ever feel that you do not have enough diapers to change them as often as you would like? No
What do you do when you do not have enough diapers? n/a
History reviewed. No pertinent past medical history.
History reviewed. No pertinent surgical history.
No current outpatient medications on file prior to visit.
No current facility-administered medications on file prior to visit.
No Known Allergies
History reviewed. No pertinent family history.
Social History as above
Patient’s medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate.
Review of Systems
Constitutional: Negative for fever, malaise/fatigue and weight loss.
HENT: Negative for congestion, ear discharge and ear pain.
Inflammation of gingiva
Eyes: Negative for discharge and redness.
Respiratory: Negative for cough, shortness of breath and wheezing.
Gastrointestinal: Negative for abdominal pain, blood in stool, constipation, diarrhea, nausea and vomiting.
Genitourinary: Negative for dysuria and hematuria.
Skin: Negative for itching and rash.
OBJECTIVE:
Pulse 148, temperature 98.2 °F (36.8 °C), temperature source Temporal, resp. rate 56, height 60 cm, weight (P) 6.11 kg (13 lb 7.5 oz), head circumference 15.75″ (40 cm).
Physical Exam
Constitutional:
General: She is active. She is not in acute distress.
Appearance: Normal appearance. She is not toxic-appearing.
HENT:
Head: Normocephalic and atraumatic. Anterior fontanelle is flat.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: No oropharyngeal exudate or posterior oropharyngeal erythema.
Comments: No erythema or swelling of gingiva
No eruption of teeth
No drainage, pus, bleeding
No tenderness to palpation
Eyes:
General: Red reflex is present bilaterally. Visual tracking is normal.
Right eye: No discharge.
Left eye: No discharge.
Extraocular Movements: Extraocular movements intact.
Conjunctiva/sclera: Conjunctivae normal.
Pupils: Pupils are equal, round, and reactive to light.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Pulses: Normal pulses.
Brachial pulses are 2+ on the right side and 2+ on the left side.
Femoral pulses are 2+ on the right side and 2+ on the left side.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal. No respiratory distress, nasal flaring or retractions.
Breath sounds: Normal breath sounds. No decreased air movement. No wheezing.
Abdominal:
General: Abdomen is flat. Bowel sounds are normal. There is no distension.
Palpations: Abdomen is soft.
Tenderness: There is no abdominal tenderness. There is no guarding.
Musculoskeletal:
General: No swelling or tenderness. Normal range of motion.
Cervical back: Normal range of motion and neck supple.
Right hip: Negative right Ortolani and negative right Barlow.
Left hip: Negative left Ortolani and negative left Barlow.
Skin:
General: Skin is warm.
Capillary Refill: Capillary refill takes less than 2 seconds.
Turgor: Normal.
Findings: No rash. There is no diaper rash.
Neurological:
Mental Status: She is alert.
Motor: No abnormal muscle tone.
Primitive Reflexes: Suck normal. Symmetric Moro.
Deep Tendon Reflexes: Reflexes normal. Babinski sign absent on the right side. Babinski sign absent on the left side.
ASSESSMENT:
4 month WCC without abnormal findings. Well-appearing and growing appropriately. PE reassuring and negative for any signs of infection.
PLAN:
Well-care
Immunizations reviewed and brought up to date per orders. Received hepB, dtap, ipv, hib, pcv20, and rota.
Vitamin D prescribed: was given today.
Counseling: immunizations, teething, and well care schedule.
Follow up in 2 months for well care.
Teething
Symptoms likely associated with teething. No eruptions noted on physical exam. Okay to trial Tylenol to help with pain and discomfort.
Strict return precautions given and mother voiced understanding.
Parent/guardian verbalizes an understanding of the plan of care and has been educated on the purpose, side effects, and desired outcomes of any new medications given with today’s visit. Parent/guardian instructed to carry a copy of the patient’s current medications to share with their physicians and in the event of an emergency.
CPT code 99391 Periodic comprehensive preventive medicine reevaluation 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, established patient; infant (age younger than 1 year)
CPT 96161 Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument
ICD-10 code
Z00.129 – Encounter for routine child health examination without abnormal findings
K00.7 – Teething syndrome [Active]