In simple words: This code is for a routine checkup for a baby less than one year old who is already a patient of the doctor.The doctor will check the baby's health, talk to the parents about how to keep the baby healthy, and may order tests if needed.Any shots or other separate procedures will be billed separately.

This CPT code reports a periodic comprehensive preventive medicine reevaluation and management service for an established infant patient (less than one year old).The service encompasses an age- and gender-appropriate history, a comprehensive examination, counseling and anticipatory guidance addressing risk factor reduction, and the ordering of necessary laboratory or diagnostic procedures.Immunizations and other separately identifiable procedures are reported with separate codes.If a significant, separately identifiable problem arises requiring additional work beyond the preventive service,an additional E/M code (99202-99215) with modifier -25 should be billed.

Example 1: A 6-month-old established patient presents for a routine well-baby check. The physician performs a complete physical exam, reviews developmental milestones, discusses nutrition and sleep, and administers routine immunizations.Z00.129 (Encounter for routine child health examination without abnormal findings) is used as the diagnosis code., An 11-month-old established patient is brought in for a well-baby visit. During the exam, the physician notes a concerning heart murmur.Further evaluation is conducted, and a cardiology consult is ordered. In this case, 99391 is reported for the preventive service, and an appropriate E/M code (e.g., 99213) with modifier -25 is reported for the additional evaluation of the heart murmur., A 9-month-old established patient comes in for a well visit. The parents have concerns about the baby's feeding habits. The physician spends significant time counseling the parents on various feeding techniques and strategies.While the initial counseling is included in 99391, if the time spent exceeds that usually associated with a routine well visit, an additional E/M code with modifier -25 could be considered.

Complete documentation should include the comprehensive history and physical examination performed, details of counseling and anticipatory guidance provided, results of any ordered tests, and any significant findings or interventions.The documentation must support the medical necessity of the visit and the level of service provided.The age and gender of the patient must be explicitly stated.

** Always ensure that the documentation fully supports the medical necessity and the level of service rendered.Consult payer-specific guidelines for potential additional requirements or limitations.