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.