Healthcare visits, especially for children, can sometimes feel overwhelming for both parents and providers. One key aspect of these visits is proper documentation and billing, often done through CPT (Current Procedural Terminology) codes. Among these, CPT Code 99391 plays an essential role in preventive care for children. But what does this code actually mean? Why is it important? And how can both providers and parents understand its value?
In this guide, we’ll break down CPT 99391 in simple terms covering what it includes, when it’s used, and why it matters.
What is CPT Code 99391?
CPT Code 99391 refers to a preventive medicine evaluation and management (E/M) service provided to an established patient under 1 year of age. This means the child has visited the practice before, and this visit is a routine check-up, not prompted by illness or injury.
It’s commonly used for well-baby visits, where pediatricians assess the baby’s overall health, growth, development, and provide vaccinations as needed.
Definition from AMA:
“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 appropriate immunization(s) and laboratory/diagnostic procedures.”
Key Elements of CPT 99391
When providers bill using CPT Code 99391, they’re referring to a comprehensive visit that typically includes:
- Complete Physical Exam
- Head-to-toe assessment of the infant
- Growth measurements: height, weight, head circumference
- Developmental screening based on age milestones
- Medical History Review
- Birth history, feeding patterns, sleep, bowel movements, and developmental progress
- Counseling and Guidance
- Discussion with parents about nutrition, sleep habits, safety tips, and emotional development
- Vaccinations and Labs
- Administering age-appropriate immunizations
- Ordering necessary lab tests (e.g., lead screening, if needed)
- Parental Concerns
- Time to address any specific concerns or questions parents may have
When is CPT Code 99391 Used?
CPT 99391 is typically used during routine check-ups for infants under 1 year of age who are already established patients at the practice. For example, if a baby had their first visit at birth and is now coming back for their 2-month or 6-month well visit, this code may apply.
Here’s a sample timeline of when 99391 might be used:
- 1 month
- 2 months
- 4 months
- 6 months
- 9 months
Note: If it’s the first visit ever to the clinic, providers may instead use CPT 99381 (for new patients under 1 year).
Why Is CPT 99391 Important for Providers?
For healthcare providers, accurate coding ensures:
- Proper reimbursement for services rendered
- Compliance with insurance and federal regulations
- Documentation of preventive care for legal and clinical reasons
Using CPT Code 99391 appropriately reflects that the visit was preventive and age-specific, rather than problem-focused or acute.
Additionally, for practices that outsource medical billing services, correct use of this code is critical for clean claims and faster payments. Professional billing services ensure CPT codes like 99391 are applied with supporting documentation, reducing the risk of denials.
Why Should Parents Understand CPT Code 99391?
For parents, knowing about CPT 99391 helps them:
- Understand the value of preventive care and how it differs from sick visits
- Review insurance Explanation of Benefits (EOB) statements accurately
- Advocate for their child’s health by asking informed questions during visits
- Avoid surprise bills by understanding which visits are typically covered by insurance under preventive care
Most insurance plans, under the Affordable Care Act (ACA), cover preventive visits for children at no additional cost to the parents. That means CPT Code 99391 is usually fully covered when it’s part of a recommended well-child schedule.
CPT Code 99391 vs Other Related Codes
| CPT Code | Patient Type | Age | Purpose |
| 99391 | Established | < 1 year | Well-child visit |
| 99381 | New | < 1 year | Initial preventive visit |
| 99392 | Established | 1–4 years | Toddler/child check-up |
| 99213/99214 | Established | Any age | Sick visits / Problem-focused E/M |
Understanding this distinction helps avoid confusion when reviewing medical bills or requesting clarification from providers.
Billing Considerations for Providers
To successfully bill CPT Code 99391, providers should ensure:
- The child is under 1 year and an established patient
- The visit includes documentation of comprehensive history, exam, and counseling
- No major illness or acute condition was the primary reason for the visit
If an illness or problem is addressed in addition to the preventive exam, an additional E/M code (like 99213) may be used with modifier -25 to indicate a separately identifiable service. However, strict documentation rules apply.
Example:
A 6-month-old baby comes in for a routine check-up (CPT 99391), but also has a mild ear infection addressed during the same visit. The provider may bill both 99391 and 99213-25.
How Outsource Medical Billing Services Help with CPT 99391
For pediatric clinics and family practices, using a reliable outsourced medical billing service can:
- Eliminate coding errors that result in claim denials
Maximize reimbursement by identifying billable services during well-child exams - Ensure compliance with payer-specific requirements (e.g., Medicaid vs private insurance)
- Save time for clinicians to focus on care rather than billing logistics
Such services also help track immunization schedules, developmental screenings, and follow-up appointments, key components often bundled with CPT Code 99391.
Final Thoughts
Understanding CPT Code 99391 is essential for both parents and providers. For providers, it ensures accurate billing and continuity of care documentation, especially when distinguishing between preventive services and those requiring a diagnosis like the G89.29 diagnosis code for chronic pain or neck pain ICD-10 codes for musculoskeletal concerns. For parents, it empowers them to track their child’s health, understand insurance benefits, and appreciate the preventive measures taken during infancy.
Whether you’re a concerned parent or a busy pediatrician, knowing how and when to use CPT 99391 leads to better care, fewer billing errors, and healthier outcomes for the youngest patients.
FAQs About CPT Code 99391
Is CPT 99391 covered by insurance?
Yes, in most cases it is fully covered under preventive care benefits for children, especially under ACA-compliant plans.
Can CPT 99391 be billed with a vaccine administration code?
Yes. Vaccine administration (e.g., CPT 90460) and vaccine product codes (e.g., 90698) can be billed alongside 99391.
What documentation is required to support CPT Code 99391?
A detailed record of the physical exam, patient history, anticipatory guidance, and any screenings or immunizations provided.
Can providers bill CPT 99391 for a sick child?
No. If the visit is primarily for an illness, a different E/M code should be used. If the illness is addressed in addition to the well visit, then both may be billed with appropriate modifiers and documentation.