The Curious Case of Billing for Well Child Visits

The services provided as part of a well-child checkup are generally defined by the health insurance company. These checkups include an assessment of growth and development, screening for medical and psychosocial problems, anticipatory guidance to aid parents in the next stage of their child’s development, a review of your child’s vaccination history and status and administration of any vaccines necessary. We are happy to address questions that come up during the visit, and most can be answered simply and fall within the scope of this well child checkup.

Sometimes, a more significant health problem will be identified over the course of this visit. If so, the time and effort spent addressing these concerns go beyond the scope of what is covered by a well-child exam. Some examples include:

  • a new problem that requires diagnostic testing, referral to a specialist or sub-specialist, significant change in treatment for an existing concern, or prescription of a new medication. For example, at a 9-month baby visit, baby John is weighed and measured and is found not to have gained weight appropriately. Lab testing is done to check for anemia and a special feeding plan is set up.
  • an in-depth discussion of a chronic medical issue that requires a detailed review of the existing treatment plan, and/or a change in treatment or a new diagnostic workup. For example, young Cara has congenital hypothyroidism and is on thyroid hormone replacement. Her recent labs are reviewed and her growth is assessed and a change is made to her medication. She is also referred back to Endocrinology for follow up.

When one of these scenarios arises, your doctor will typically submit billing codes for both a well-child visit and a “modifier” that indicates that an illness or problem was treated in the same visit. This is standard billing practice among all primary care providers and is accepted as standard practice by government agencies and by private health insurers. While most plans cover preventive care in full with no co-pay, there is often a co-pay, co-insurance or deductible associated with the “modifier” billing codes.

It is important to review chronic health conditions, so we encourage you to schedule this visit separately if possible.

Well child visits (routine Preventive Care)

  • Assess growth and development

  • Breastfeeding support

  • Exercise recommendations

  • Routine vaccinations

  • Screening for medical and psychosocial problems

  • Anticipatory guidance (what to expect coming up)

Visit is no longer “preventive” when:

  • A significant problem is identified and treated during the visit
  • Chronic problems are managed during the visit