Well-Child Visit Billing: How to Choose the Right CPT by Age

Well-child visits are routine for pediatric practices, but well-child visit billing is not always as straightforward.

Take a four-year-old coming in for a preventive checkup. Should the visit be billed with 99382 or 99392? The answer depends on the child's age and whether the patient is new or established.

Getting that distinction right can help prevent unnecessary claim corrections and payment delays. This guide breaks down well-child visit CPT codes by age, explains the new versus established patient distinction, and covers the billing details your team should check before submitting the claim.

 

What Well-Child Visit Billing Actually Means

A well-child visit is a routine pediatric checkup. The provider reviews the child's health, growth, and development, does a physical exam, runs age-appropriate screenings, and gives any vaccines that are due. Some visits also handle counseling for the parent and a quick behavioral or developmental check.

Well-child visit billing is how you turn that visit into a paid claim. Under commercial coverage, it's a preventive visit. Under Medicaid, it's part of EPSDT, short for Early and Periodic Screening, Diagnostic, and Treatment. The base CPT codes stay the same either way. What changes is the documentation, the modifiers, and the payer rules layered on top. State Medicaid programs also add their own screening codes and forms on top of the federal EPSDT base.

Every well-child claim comes down to two questions.

• Is the patient new or established?

• How old was the child on the date of the visit? 

Once those are clear, the billing team can move on to vaccines, screenings, same-day sick visits, documentation, and payer-specific requirements.

For a practical breakdown of preventive CPT codes, modifier 25, vaccine billing, screenings, and pediatric documentation, see our guide to billing pediatric preventive visits.

How Age Determines the Right Preventive Visit CPT Code

Pediatric medical billing splits preventive codes into two sets. New patient codes and established patient codes. Age picks the specific code inside each set.

New Patient Well-Child CPT Codes

Use these when the child is new to your practice or your specialty group:

• 99381: under 1 year

• 99382: ages 1 through 4

• 99383: ages 5 through 11

• 99384: ages 12 through 17

• 99385: ages 18 through 39

Established Patient Well-Child CPT Codes

Use these for patients your practice has seen before:

• 99391: under 1 year

• 99392: ages 1 through 4

• 99393: ages 5 through 11

• 99394: ages 12 through 17

• 99395: ages 18 through 39

The age band goes by the child's age on the date of service. Not the age at the last visit. Not the age at the next one scheduled.

New vs. Established Patient Rule That Can Affect Billing

For well-child visit billing, first check whether the child is new or established. A patient is generally established if they were seen by a provider in the same specialty and group within the past three years. If not, they may qualify as a new patient under the applicable coding rules.

The three-year rule is easy to miss. A child your practice saw as a baby does not automatically become new later. Check the date of the last qualifying visit before selecting the well-child visit CPT code.

New and established patients use different preventive CPT code ranges. Choosing the wrong patient status can lead to claim corrections, denials, or missed reimbursement.

Before submitting the claim, check the patient's last qualifying visit date, specialty, and provider group. This simple step can help your team select the right preventive visit code the first time.

How to Bill a Well-Child Visit and Sick Visit on the Same Day

Kids show up sick during well-child visits all the time. That's fine. You can bill both.

The trick is modifier 25. Attach it to the sick E/M code, not the preventive code. The chart has to show two separate things that happened. The well-child components on one side. The sick complaint, exam, and plan on the other.

Skip the modifier, and one claim pays while the other denies. Skip the documentation, and the payer can pull the money back on audit. Our guide to modifier 25 pediatric billing covers the exact scenarios that pass and the ones that don't.

EPSDT Billing by Age: What Changes From Infancy to Adolescence 

EPSDT billing follows Medicaid’s preventive care requirements for children and young adults under 21. The services and screenings expected during a visit can change as the child gets older, so the billing team needs to consider the patient’s age along with the applicable Medicaid rules.

The Bright Futures schedule outlines preventive care by age. A 9-month visit, for example, may involve different screenings than a 3-year visit, while adolescent visits can include behavioral or depression screening that would not typically apply to a toddler.

Missing an age-appropriate screening may not always prevent a claim from being paid, but it can create problems during a later review or audit. Before submitting an EPSDT claim, check the requirements for the child’s age and the specific state Medicaid program.

For more guidance on state-specific requirements, see our pediatric Medicaid billing services resource.

A Real Example: One Child, Three Visits, Three Different Billing Considerations

Imagine Mia, who has been coming to the same pediatric practice since she was a baby.

At 9 months, her preventive visit may include age-appropriate developmental screening and other assessments expected at that stage.

Mia returns at 3 years old. This time, the provider is looking at a different set of developmental, behavioral, vision, and other preventive needs based on her age.

Then Mia comes back at 12. The visit has moved into adolescence, where preventive care may include areas such as behavioral health or depression screening.

The practice cannot simply use the same preventive checklist from Mia's 9-month visit and apply it again at age 12.

How to Prevent Age-Related Pediatric Claim Denials 

Most age-related pediatric claim denials come from a short list.

• A new-patient code is billed even though the child was seen by the same practice within the past three years

• An adolescent preventive code is used for a patient who had already turned 18 before the date of service

• The patient's age in the chart does not match their actual age on the date of service

These are usually preventable errors. A good claim scrub should compare the patient's date of birth, date of service, patient status, and selected CPT code before the claim leaves the practice. For well-child visit billing, that simple check can make a noticeable difference. It helps catch incorrect preventive visit coding early, reduces rework, and improves the chances of sending clean claims the first time 

Why Specialized Pediatric Billing Services Can Reduce Age-Based Coding Errors 

An in-house biller who also handles phones, prior auths, and scheduling doesn't have time to double-check every birthday against every code. A pediatric billing services team builds birthday-aware scrubs into every claim.

That's the difference between a clean claims rate that sits at 90 percent and one that sits closer to 98. Our overview of pediatric medical billing services covers what to look for in a specialty partner.

FAQ

1. What are the CPT codes for well-child visits?

Well-child visits generally use 99381–99385 for new patients and 99391–99395 for established patients, with the specific code selected based on the child's age and patient status.

2. What is the CPT code for a well visit for a 2-year-old child?

For a 2-year-old established patient, 99392 is generally used for the preventive visit. If the child is new to the practice, 99382 may apply.  

3. What are the CMS annual wellness visit guidelines for 2026? 

For Medicare, CMS uses G0438 for the initial Annual Wellness Visit and G0439 for subsequent visits. An AWV can generally be billed once every 12 months.