Code: 99381
Description: Initial comprehensive preventive medicine evaluation 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, new patient; infant (age under 1 year)
Context: This code is specifically used for comprehensive preventive medicine services for infants under the age of one year. It covers a thorough evaluation and management process tailored to the needs of a new patient in this age group.
Guidelines for Proper Use
- Specific Use for Preventive Medicine in Infants: Apply 99381 for initial comprehensive preventive evaluations of infants under one year old. This includes a full history, examination, and appropriate counseling or guidance.
- Documentation of Comprehensive Services: Ensure that healthcare providers’ documentation reflects the age-appropriate preventive services provided, including any counseling, guidance, or interventions.
- New Patient Distinction: This code is used for new patients only. Do not use it for follow-up visits or for established patients.
- Inclusion of Preventive Services Components: The code covers various components of preventive care such as risk factor reduction interventions and may include the ordering of laboratory or diagnostic procedures if deemed necessary.
- Compliance with Preventive Medicine Guidelines: Use 99381 in accordance with standard preventive medicine guidelines for infants, as well as payer-specific rules.
Common Misuses of 99381
- Using for Established Patients: A common misuse is applying 99381 for established patients. This code is specifically for initial evaluations of new patients.
- Application to Older Age Groups: Misuse occurs if 99381 is used for patients older than one year. There are different codes for other age groups.
- Omission of Comprehensive Elements: This code should not be used for visits that do not include a comprehensive evaluation and management as described.