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 - 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.
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 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 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.
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.