Periodic comprehensive preventive medicine, established patient, age <1 year
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Frequency limit - annual preventive visit
Very CommonPreventive medicine visits (99391-99397) are typically covered once per calendar year or once per 12 months, depending on payer. Most common denial: preventive visit already performed within past year. 99391 is for established patient preventive, infant (under 1 year). Even though infants have frequent well-visits, insurance limits to annual frequency unless specific medical indication for additional visit.
Common Causes
- • Previous preventive visit within past 12 months
- • Multiple well-baby checks billed as preventive instead of problem-focused
- • Calendar year vs. rolling 12-month frequency confusion
Resolution Strategy
If truly preventive and within frequency limit, patient may self-pay or wait for next annual period. If visit addressed specific medical concerns beyond preventive screening, provider can recode as problem-focused E&M visit (99212-99215) with appropriate diagnosis codes.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Periodic comprehensive preventive visit for established patient, infant under 1 year
Common Scenarios
Documentation Requirements
- Age-appropriate interval history
- Complete physical examination
- Developmental screening
- Anticipatory guidance
- Growth chart update
- Parent counseling and education
Coding Guidelines
Bundling Rules
- Can bill problem-focused E/M same day with modifier 25
- Vaccines billed separately
Exclusions
- Do not use for new patients (use 99381)
- Do not use for age ≥1 year (use 99392-99394)
Coding Notes
Clinical scenarios
- Age-appropriate interval history
- Complete physical examination
- Developmental screening
- Age-appropriate interval history
- Complete physical examination
- Developmental screening
- Age-appropriate interval history
- Complete physical examination
- Developmental screening
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Frequently Asked Questions
CPT 99391 is the billing code for "Periodic comprehensive preventive medicine, established patient, age <1 year". Periodic comprehensive preventive visit for established patient, infant under 1 year
Medicare pays approximately $95.10 for CPT 99391 (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 99391 has a total RVU of 2.40, broken down as: Work RVU 1.38, Practice Expense RVU 0.92, and Malpractice RVU 0.10. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99391 is "Frequency limit - annual preventive visit". Preventive medicine visits (99391-99397) are typically covered once per calendar year or once per 12 months, depending on payer. Most common denial: preventive visit already performed within past year. 99391 is for established patient preventive, infant (under 1 year). Even though infants have frequent well-visits, insurance limits to annual frequency unless specific medical indication for additional visit. Common causes include: Previous preventive visit within past 12 months; Multiple well-baby checks billed as preventive instead of problem-focused. Appeal success rate is approximately 10-30%.
Key documentation requirements for CPT 99391 include: Age-appropriate interval history; Complete physical examination; Developmental screening; Anticipatory guidance. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99391: Can bill problem-focused E/M same day with modifier 25. Vaccines billed separately Use an NCCI bundling checker to verify specific code combinations before billing.
The typical time requirement for CPT 99391 is Typical: 25-35 minutes. Time-based codes require documentation of the actual time spent providing the service.