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TRICARE Policy Manual 6010.63-M, April 2021
Medicine
Chapter 7
Section 2.5
Well-Child Care
Issue Date:  April 19, 1983
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT 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 - 99174, 99177, 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.
3.0  POLICY
Well-child care is covered for beneficiaries from birth to age six when services are provided by the attending pediatrician, family physician, ophthalmologist or optometrist, certified Nurse Practitioner (NP), or certified Physician Assistant (PA). Well-child services are considered preventive and are subject to the same cost-sharing/copayment and authorization requirements prescribed under the TRICARE Clinical Preventive Services benefit (see Section 2.1 and 2.2).
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 website (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 (US) are not covered. EXCEPT for immunizations required by dependents of active duty military personnel who are traveling outside the US 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 United States (US) 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 Guidelines (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 calendar 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:
4.6.1  Immunizations as indicated in paragraph 4.3.
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: (Current Procedural Terminology (CPT) 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.
4.7  Effective December 2, 2019, TRICARE reimburses separately for instrument-based vision screening (CPT codes 99174 and 99177) for children age one to age six when provided by a physician other than an ophthalmologist or optometrist as part of a well-child care program.
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