1.0 CPT
PROCEDURE CODES
54150, 54160, 54161, 81000
- 81015, 81099, 83655, 84030, 84035, 85014, 85018, 86580, 86585, 90465
- 90468, 90471 - 90474, 90476 - 90748, 92002, 92004, 92012, 92014,
92015, 92551, 92585 - 92588, 96110, 99172, 99173, 99381 - 99383,
99391 - 99393, 99460 - 99463, 99499.
2.0 DESCRIPTION
Well-child care includes routine newborn care,
health supervision examinations, routine immunizations, periodic
health screening, and developmental assessment in accordance with
the American Academy of Pediatrics (AAP) and Bright Futures guidelines.
4.0 POLICY
CONSIDERATIONS
4.1 Visits for diagnosis or treatment of an illness
or injury are not included in the well-child benefit. Benefits should
be extended on the basis of the medical necessity for the services.
4.2 For children
whose health screening and immunizations may not be current, payment
may be made for well-child visits and immunizations up to midnight
of the day prior to the day the child turns six years old, and thereafter
under the TRICARE Clinical Preventive Services benefit (see
Sections 2.1 and
2.2).
4.3 Immunizations
are covered for the age appropriate dose of vaccines that have been recommended
and adopted by the Advisory Committee on Immunization Practices
(ACIP) and accepted by the Director of the Centers for Disease Control
and Prevention (CDC) and the Secretary of Health and Human Services
(HHS) and published in a CDC
Morbidity and Mortality Weekly
Report (MMWR). Refer to the CDC’s web site (
http://www.cdc.gov)
for access to the MMWRs and a current schedule of CDC recommended
vaccines. Immunizations recommended specifically for travel outside the
United States (U.S.) are not covered. EXCEPT for immunizations required
by dependents of active duty military personnel who are traveling
outside the U.S. as a result of an active duty member’s duty assignment,
and such travel is being performed under orders issued by a Uniformed
Service.
Note: The procedure codes in this policy
are not necessarily an all-inclusive list of vaccines currently
recommended for use in the U.S. by the CDC’s ACIP.
4.4 Well-child
care for newborns includes the routine care of the newborn in the
hospital, newborn circumcision, and newborn metabolic screening
as recommended by the AAP. In 2005, the AAP endorsed the newborn
screening report from the American College of Medical Genetics that significantly
expanded metabolic screening for newborn infants. These conditions
include a core panel of 28 conditions and an additional secondary
panel of 25 conditions. The most recently endorsed conditions for
screening are reflected in the
Department of Veterans
Affairs/Department of Defense
(
DVA/DoD)
Clinical Practice Guideline
s (CPG) (https://www.healthquality.va.gov/).
Only routine well-child care for newborns is covered as part of
the mother’s maternity episode, i.e., a separate cost-share is not
required for the infant.
Note: Male circumcision
performed during newborn period (0 - 30 days) is covered. Male circumcision
performed outside the newborn period due to medical complications
at birth or during the newborn period that prevented performing
the circumcision within the newborn period, may be covered up to
30 days after discharge. Male circumcision performed after the newborn
period without medical complications at birth, may be covered if
medically necessary and otherwise authorized for benefits.
4.5 Each office
visit for well-child care includes the following services:
4.5.1 History
and physical examination and mental health assessment.
4.5.2 Developmental
and behavioral appraisals, which may include questions about a child’s language,
motor, cognitive, social, and emotional development.
4.5.2.1 Height
and weight should be measured regularly throughout infancy and childhood.
4.5.2.2 Head circumference
should be measured for children through 24 months of age.
4.5.2.3 Sensory
screening: vision, hearing (by history).
4.5.2.3.1 Eye and
vision screening by primary care provider during routine examination
at birth, and approximately six months of age.
4.5.2.3.2 According
to the AAP and the Joint Committee on Infant Hearing (JCIH), all
newborns should undergo hearing screening using evoked Otoacoustic
Emissions (OAE) testing or automated Auditory Brainstem Response
(ABR) testing before one month of age; preferably, before leaving
the hospital. An infant who does not pass the hearing screening
should undergo appropriate audiological and medical evaluations
to confirm the presence of a hearing loss at no later than three
months of age.
4.5.2.3.3 All children
should undergo hearing screening (by history) at each well-child
visit, and children with possible hearing impairments should be
referred for appropriate testing.
4.5.2.4 Dental
screenings.
4.5.2.5 Discussion
with parents, anticipatory guidance.
4.6 The following
specific services are covered in a program of well-child care:
4.6.2 Tuberculin test: at 12 months
of age and once during second year of age.
4.6.3 Hemoglobin or hematocrit testing:
once during first year of age, once during second year of age.
4.6.4 Urinalysis:
once during first year of age, once during second year of age.
4.6.5 Annual
blood pressure screening for children between three and six years
of age.
4.6.6 Blood lead test: (CPT procedure code 83655):
Assessment of risk for lead exposure by structured questionnaire
based on the CDC’s Preventing Lead Poisoning in Young (October 1991) during
each well-child visit from age six months to under six years of
age.
4.6.7 Health guidance and counseling, including breast
feeding and nutrition counseling.
4.6.8 One routine eye examination
by an ophthalmologist or optometrist every two years beginning at
age three. The routine eye exams offered between the ages of three
and six should include screening for amblyopia and strabismus.
4.6.9 Additional
services or visits required because of specific findings or because
the particular circumstances of the individual case are covered
if medically necessary and otherwise authorized for benefits.