Summary & Overview
CPT 99381: Initial Preventive Medicine Evaluation for Infants Under 1 Year
CPT code 99381 represents the initial comprehensive preventive medicine evaluation and management for infants under one year of age. This code is a cornerstone of pediatric care, ensuring that newborns receive a thorough health assessment, including physical examination, developmental screening, and guidance for parents. The service is typically provided in an office setting and is essential for early detection of health issues and establishing a foundation for ongoing care.
Major national payers such as Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare recognize and reimburse for this preventive service. The publication provides an overview of payer coverage, clinical context, and relevant billing benchmarks for CPT code 99381. Readers will gain insight into policy updates, typical use cases, and the importance of preventive medicine visits for new patients in pediatric practice. The summary also highlights associated modifiers and related codes, offering a comprehensive look at billing and documentation requirements for this service. This information is valuable for understanding national trends in pediatric preventive care and ensuring accurate coding and reimbursement.
CPT Code Overview
CPT code 99381 is used for the initial comprehensive preventive medicine evaluation and management of an individual under 1 year of age. This service is classified as Preventive Medicine — New Patient and is typically performed in an office setting (Place of Service 11). The code covers a thorough assessment of a newborn's health, including history, examination, and anticipatory guidance, as part of routine pediatric care for infants during their first year of life.
Clinical & Coding Specifications
Clinical Context
A newborn infant, less than one year old, is brought by their parent or guardian to a pediatrician's office for an initial comprehensive preventive medicine evaluation. The visit includes a thorough assessment of the infant's health status, growth, and development, as well as a physical examination. The provider reviews the infant's medical history, performs age-appropriate screenings, and discusses preventive health measures with the family. This encounter is typically scheduled as the first well-child visit for a new patient in the practice, and takes place in an office setting (Place of Service 11).
Coding Specifications
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Modifiers:
+99358: Prolonged evaluation and management service before and/or after direct (face‑to‑face) patient care; first hour. Used when the provider spends additional time on the patient's care outside of the face-to-face encounter, such as reviewing records or coordinating care.+99359: Prolonged evaluation and management service; each additional 30 minutes. Used in conjunction with+99358when more than one hour of prolonged service is provided.
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Provider Taxonomies:
| Taxonomy Code | Specialty |
|---|---|
| 208000000X | Pediatrics Physician |
- Specialty Representation:
- Pediatrics Physician: Providers specializing in the care of infants, children, and adolescents.
Related Diagnoses
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Z00.110: Health examination for newborn under 8 days old- Used for preventive visits for newborns less than 8 days old, relevant for initial comprehensive evaluations.
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Z00.111: Health examination for newborn 8 to 28 days old- Applied to preventive visits for newborns aged 8 to 28 days, appropriate for early well-child checks.
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Z00.121: Encounter for routine child health examination with abnormal findings- Used when the preventive visit identifies abnormal findings during the examination.
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Z00.129: Encounter for routine child health examination without abnormal findings- Used for routine preventive visits where no abnormalities are found.
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Z76.1: Encounter for health supervision and care of other healthy infant and child- Used for preventive health supervision visits for healthy infants and children, relevant to the scope of
99381.
- Used for preventive health supervision visits for healthy infants and children, relevant to the scope of
Related CPT Codes
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+99358: Prolonged evaluation and management service before and/or after direct (face‑to‑face) patient care; first hour.- This code is used when the provider spends significant time on activities related to the patient's care outside the direct encounter, such as reviewing medical records or coordinating care. It is commonly used in addition to
99381when the preventive visit requires extra time.
- This code is used when the provider spends significant time on activities related to the patient's care outside the direct encounter, such as reviewing medical records or coordinating care. It is commonly used in addition to
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+99359: Prolonged evaluation and management service; each additional 30 minutes.- This code is used in conjunction with
+99358for each additional 30 minutes of prolonged service. It may be used alongside99381if the provider's non-face-to-face time exceeds one hour.
- This code is used in conjunction with
Both +99358 and +99359 are add-on codes and are not alternatives to 99381, but are used together when prolonged services are documented.
National Reimbursement Benchmarks
National mean rates for CPT code 99381 show that UnitedHealth Group has the highest average reimbursement at $148.40, while Aetna is the lowest among the major commercial payers at $108.97. The BUCA composite mean rate is $118.77, which is notably higher than typical Medicare rates for similar services, though Medicare data is not available in the input for this code.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies across payers. Aetna has the tightest range at $49.33, while Cigna exhibits the widest spread at $80.50, indicating greater variability in contracted rates. Blue Cross Blue Shield and UnitedHealth Group also show substantial dispersion, with ranges of $53.56 and $80.33, respectively.
The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.