WELL VISIT CODING AND BILLING
FREQUENTLY ASKED QUESTIONS
If you directly pay any portion of your child’s health care costs (co-pay, deductible, HSA, etc), then it is
important to have a general understanding of medical coding and billing. It’s a confusing, boring area but
Kidz1st offers the following explanations and examples to help you understand your potential financial
responsibilities.
What are medical billing codes?
Medical billing codes started in the late 1970s and were originally called Healthcare Common Procedure
Coding System (HCPCS) Level 1 codes. In the mid-1990’s, the core set of codes were further expanded
and refined and became known as Current Procedural Terminology, or CPT, codes. CPT codes are a
standardized, numerical coding system that defines every possible service, procedure, test, product, and
device that can be provided in the delivery of health care. The codes fill an 800 page book! A small subset
of CPT codes, called Evaluation and Management, or E/M, codes are used to define office visits.
Why do we need CPT codes?
Consistency in the definitions of what is performed, documented, and billed has two purposes:
1) To make sure that there is adequate and consistent payment to health care providers
2) To minimize the chance of fraud by providers and insurance companies.
What do CPT E/M codes tell us?
CPT E/M codes tell us what is typically done at office visits or the “typical resources” needed. Resources
include office expenses, provider training/skills/experience, performing the history and physical exam,
decision making complexity and risk, coordination of care, evaluating outside records, counseling, and
time. E/M codes are divided into codes for well visits and codes for acute, chronic, and follow-up visits.
Who determines which CPT codes to use for an office visit?
The health care provider who performs the services is ultimately responsible for the accuracy of the codes
billed. Larger offices may employ professional coders. It’s actually a good field to go into! However,
Kidz1st does not delegate this very important responsibility. We believe that the person who actually did
the work, the health care provider, has the best knowledge of what was actually done. So we train our
providers in the gory details of coding. And we do detailed, daily internal auditing so that patients and
insurers alike can be confident that we provide the most accurate coding possible.
Why would I want to know about billing codes?
With the country’s economic woes, we are seeing a rapidly spreading trend of employers shifting more
health care expenses, both premiums and direct costs, to employees. Ignorance may be bliss when
someone else is paying the bills but if you are paying, all of this coding information becomes relevant.
So what is included in a “typical” acute visit?
For acute, chronic, and follow-up visits, increasing levels of resources required for a “typical” visit are
assigned to increasing “levels” of codes. You will see these codes billed with the numbers 9920x and
9921x, where x is a number 1-5 depending on the level of resources needed. If a lab test or other
procedure is done, that is billed separately because it is NOT “typically” done on everybody.
What’s included in a “typical” well visit?
Coding for well visits is much trickier. Well visit codes will be shown as 9938x or 9939x, where x is
again 1-5 but now represents the age of the patient. “Typical” resources needed are fairly consistent from
age to age so CPT E/M codes define a “typical minimum” that must be done. There are, however, two
general scenarios in which “additional” resources are needed and, therefore, coded and billed:
1) When there are “expert recommendations” that certain procedures are necessary as the
“standard of care.” There are MANY of these, such as immunizations, developmental
assessment, hearing and visions screening tests, anemia and cholesterol blood tests, and screening
for health and behavior problems. Each of these “recommendations” has their own unique CPT
codes as they require a different set and level of resources. These CAN be predicted ahead of time.
2) When there are “additional concerns” during the well visit NOT “typically” part of a well visit.
a. The concern may be expressed by the parent/patient or identified during the visit by the
provider or by screening tests/questionnaires.
b. The concern may be a new problem or follow-up on an existing problem.
c. Since the resources required to deal with the concern are similar in nature to those needed
for a separate acute, chronic, and follow-up visits, the acute visit codes 9920x and 9921x
are used.
d. The “-25 modifier” is added to the end of the acute code to show that, while at a well visit,
a potential concern was identified that required extra resources.
e. The appropriate “level” of acute code is chosen that matches the amount of additional
“resources” required.
f. The modified code is only billed if the concern and the extra work meet certain strict
criteria so that this modified code is not misused/overused.
g. Most of the time you CAN NOT predict ahead if a “-25 modifier” code will be used.
Is this new, especially these -25 modifier codes?
Codes for various “expert recommendations” have been used for many years. The -25 modifier was
approved in 2007 to recognize the extra resources needed in certain situations. Kidz1st has been using
them since 2009. You may not have previously noticed if your insurance paid the these codes.
So, which of these codes will I be expected to pay and how much?
That question is best answered by your health insurance company. Take advantage of the Kidz1st
Insurance Worksheet to help you understand what is covered 100%, what is not covered at all, what has a
co-pay or co-insurance, and what will apply to your deductible.
I called my insurance company and they said these codes should be
included in the well visit code and not billed separately.
This process is called “bundling” and, in the above situations, is unethical and potentially illegal.
Bundling is used as an excuse for insurers to not pay what they are contractually obligated to pay. While
there are some CPT codes that supposed to be bundled, none of the above coding examples are included.
If I only knew this ahead of time, I could plan my health care spending
budget better!
You are absolutely correct! That is why we created and offered the Kidz1st Insurance Worksheet for your
use. In addition, if we have your email address, we will soon be sending you the expected codes and
charges for your child’s next well visit along with our email reminder of your child’s appointment time
and date. You may also call at any time and ask which codes and charges may be applicable for a visit.
WELL VISIT BILLING AND CODING EXAMPLE SCENARIOS
SCENARIO #1
Jacob comes in for his 4 month well baby visit. Mom has no concerns. History and physical exam reveal
no potential concerns. Mom completes the development and postpartum depression screening
questionnaires which reveal no concerns. Jacob receives his recommended immunizations.
99391
96110
96110
90698/90460/90461x4
90670/90460
90680/90460
BILLING CODES
Established patient, well visit 0-11 months old
Developmental screening questionnaire
Postpartum depression screening questionnaire
Pentacel (DTaP-IPV-Hib) vaccine and its administration
Prevnar (PCV7) vaccine and its administration
Rotavirus (RV5) vaccine and its administration
SCENARIO #2
Mom states that Jacob has mild cough and congestion for 2 days with no fever and no other symptoms.
History and physical exam reveal only mild nasal congestion. The provider discusses basic treatment for
the cold. Jacob receives his recommended immunizations. The rest of the visit is as in #1above.
BILLING CODES
99391
Established patient, well visit 0-11 months old
96110
Developmental screening questionnaire
96110
Postpartum depression screening questionnaire
90698/90460/90461x4 Pentacel (DTaP-IPV-Hib) vaccine and its administration
90670/90460
Prevnar (PCV7) vaccine and its administration
90680/90460
Rotavirus (RV5) vaccine and its administration
99212-25 is NOT billed because the extra resources required did NOT meet the strict
criteria to bill this code
SCENARIO #3
Mom states that Jacob has had an itchy red rash on his face, elbows, and knees for a couple weeks. Mom
expresses no other concerns. Physical exam reveals mild inflammatory eczema affecting the above areas
and is otherwise normal. Jacob is diagnosed with mild eczema. The provider discusses basic skin care
with mom and recommends the use of over the counter moisturizing cream and hydrocortisone cream.
The rest of the visit is as in #1above.
99391
96110
96110
90698/90460/90461x4
90670/90460
90680/90460
99212-25
BILLING CODES
Established patient, well visit 0-11 months old
Developmental screening questionnaire
Postpartum depression screening questionnaire
Pentacel (DTaP-IPV-Hib) vaccine and its administration
Prevnar (PCV7) vaccine and its administration
Rotavirus (RV5) vaccine and its administration
Acute visit – new problem, OTC medications, followup as needed
SCENARIO #4
Mom states that Jacob has mild cough and congestion for 2 days with no fever and no other symptoms.
History and physical exam reveal nasal congestion and a right ear infection. The provider discusses the
ear infection, home care, prescribes an antibiotic, and recommends follow-up in 10 days. The rest of the
visit is as in #1above.
BILLING CODES
99391
Established patient, well visit 0-11 months old
96110
Developmental screening questionnaire
96110
Postpartum depression screening questionnaire
90698/90460/90461x4 Pentacel (DTaP-IPV-Hib) Vaccine and Administration
90670/90460
Prevnar (PCV7) Vaccine and Administration
90680/90460
Rotavirus (RV5) Vaccine and Administration
99213-25
Acute visit – new problem, prescription medication, followup
SCENARIO #5
Mom states that Jacob has mild cough and congestion for 2 days with no fever and no other symptoms.
History and physical exam reveal nasal congestion and a right ear infection. Screening questionnaires
reveal possible developmental delay but no postpartum depression. The provider discusses the ear
infection, prescribes an antibiotic, recommends follow-up in 10 days, and discusses Jacob’s possible
developmental delay. Jacob is referred to Early Intervention for further evaluation. The rest of the visit is
as in #1above.
BILLING CODES
99391
Established patient, well visit 0-11 months old
96110
Developmental screening questionnaire
96110
Postpartum depression screening questionnaire
90698/90460/90461x4 Pentacel (DTaP-IPV-Hib) Vaccine and Administration
90670/90460
Prevnar (PCV7) Vaccine and Administration
90680/90460
Rotavirus (RV5) Vaccine and Administration
99214-25
Acute visit – multiple new problems, prescription medication,
followup needed, referral recommended
SCENARIO #6
Jacob has a history of congenital hypothyroidism. He is followed by a pediatric endocrinologist. Mom
states that he has been completely well. She has a followup appointment in 1 week but wants the lab tests
done at Crittenton Hospital before the visit. After questioning, mom states that she has missed some doses
of his medication. The provider discusses the importance of consistent treatment, reads the last consultant
report and labs, and writes an order for the next set of labs. Two days later, the provider checks the new
labs and determines that Jacob’s thyroid level is low. The results are faxed to the specialist and the mother
is called to remind her to keep the specialist followup appointment. The rest of the visit is as in #1above.
BILLING CODES
99391
Established patient, well visit 0-11 months old
96110
Developmental screening questionnaire
96110
Postpartum depression screening questionnaire
90698/90460/90461x4 Pentacel (DTaP-IPV-Hib) Vaccine and Administration
90670/90460
Prevnar (PCV7) Vaccine and Administration
90680/90460
Rotavirus (RV5) Vaccine and Administration
99215-25
Chronic Followup visit – followup existing chronic problem,
patient education, lab test ordered, consultant report and labs
reviewed