Initial comprehensive preventive medicine, age <1 year
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Age doesn't match code range - infant under 1 year
Very Common99381 is specifically for new patient preventive visits, infant (younger than 1 year). Common denial when patient age at visit doesn't fall within age range. If child is 1 year or older at visit date, must use 99382 (1-4 years). Age calculated on date of service, not date of birth year. This is most common preventive medicine denial across all age categories.
Common Causes
- • Child turned 1 year old before visit date but 99381 still billed
- • Wrong code selected in EMR template
- • Age miscalculated or birthday not updated in system
Resolution Strategy
Verify patient age at date of service. If under 1 year, appeal with date of birth proof. If 1 year or older, correct to appropriate code (99382, 99383, or 99384) and resubmit.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Initial comprehensive preventive medicine visit for new patient, infant under 1 year
Common Scenarios
Documentation Requirements
- Comprehensive age-appropriate history
- Complete physical examination
- Developmental screening and assessment
- Anticipatory guidance and counseling
- Risk factor assessment
- Growth chart documentation (height, weight, head circumference)
Coding Guidelines
Bundling Rules
- Can bill with problem-focused E/M same day using modifier 25 on E/M
- Vaccines billed separately (90460-90461, 90471-90474)
Exclusions
- Do not use for established patients (use 99391)
- Do not use for age ≥1 year (use 99382-99384)
Coding Notes
Clinical scenarios
- Comprehensive age-appropriate history
- Complete physical examination
- Developmental screening and assessment
- Comprehensive age-appropriate history
- Complete physical examination
- Developmental screening and assessment
- Comprehensive age-appropriate history
- Complete physical examination
- Developmental screening and assessment
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Frequently Asked Questions
CPT 99381 is the billing code for "Initial comprehensive preventive medicine, age <1 year". Initial comprehensive preventive medicine visit for new patient, infant under 1 year
Medicare pays approximately $106.10 for CPT 99381 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99381 has a total RVU of 2.64, broken down as: Work RVU 1.50, Practice Expense RVU 1.03, and Malpractice RVU 0.11. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99381 is "Age doesn't match code range - infant under 1 year". 99381 is specifically for new patient preventive visits, infant (younger than 1 year). Common denial when patient age at visit doesn't fall within age range. If child is 1 year or older at visit date, must use 99382 (1-4 years). Age calculated on date of service, not date of birth year. This is most common preventive medicine denial across all age categories. Common causes include: Child turned 1 year old before visit date but 99381 still billed; Wrong code selected in EMR template. Appeal success rate is approximately 70-80%.
Key documentation requirements for CPT 99381 include: Comprehensive age-appropriate history; Complete physical examination; Developmental screening and assessment; Anticipatory guidance and counseling. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99381: Can bill with problem-focused E/M same day using modifier 25 on E/M. Vaccines billed separately (90460-90461, 90471-90474) Use an NCCI bundling checker to verify specific code combinations before billing.
The typical time requirement for CPT 99381 is Typical: 30-40 minutes. Time-based codes require documentation of the actual time spent providing the service.