Preventive Care Billing Guidelines

Primary Wellness Visit Codes

The American Academy of Pediatrics recommends using CPT codes 99381-99394 for preventive care services, which are the standard codes for comprehensive wellness examinations across all age groups, including those covered under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program 1, 2
These codes are structured by patient age and whether the patient is new or established to the practice, allowing for accurate billing and reimbursement 1

The American Academy of Pediatrics suggests using CPT code 96110 when developmental screening is performed during a wellness visit, reported in addition to the preventive care E/M code with modifier 25 appended to the preventive care code 1, 2
Code 96110 does not include physician work—it covers non-physician staff administering and scoring the screening tool, while the physician's interpretation is bundled into the E/M code 2
CPT code 96111 is used for extended developmental testing (typically up to 1 hour) provided by the medical provider, including evaluation interpretation and report, also reported in addition to E/M services 1, 2

For complex wellness visits that require significantly more time or complexity than typical, the American Academy of Pediatrics recommends using higher-level outpatient codes (99214-99215 for established patients, 99204-99205 for new patients) instead of or in addition to preventive care codes 1, 2
99214 is appropriate for detailed evaluations that are moderately complex or take at least 25 minutes with more than half spent counseling 1, 2
99215 is used for comprehensive, highly complex evaluations or those taking 40 minutes with more than half spent counseling 1, 2

CPT codes 99354-99355 can be added when face-to-face outpatient visits require considerably more time than typical—99354 for the first 30-74 minutes of prolonged services, and 99355 for each additional 30 minutes 1, 2
CPT codes 99358-99359 are available for non-face-to-face prolonged services using the same time increments 1, 2

The American Academy of Pediatrics advises against using standard office visit codes (99211-99215) for routine wellness care when dedicated preventive care codes exist, as these may be rejected by payers 3
Modifier 25 should always be appended to the preventive care code when billing separately identifiable E/M services on the same day as screening procedures like 96110 2