Date Issued: 4/1/2025
Medicaid members who are less than 21 years of age are covered for an annual wellness visit and do not have to wait 12 months from the date of their last wellness visit to be covered. Wellness visits are covered once every calendar year.
You can also complete a well-child visit when a child comes in for a sick visit. You should do this after determining that the condition, illness, or injury that led to the sick visit does not impede the ability to complete a well-child visit and that the child is eligible for the well-child visit, per their Care Gap Report. When services are documented and billed properly, offices can close care gaps. We want to ensure that our providers are reimbursed properly for the care provided.
Your office can submit claims for both a sick visit and a preventive child wellness visit for services provided on the same day, by adding the Modifier 25 to the claim. All components must be addressed. Providers must properly document the medical record to support the CPT codes and the E/M codes billed for the child wellness visit.
Regular checkups are important at all ages. As a reminder, be sure to schedule annual wellness visits for all your patients, even if 365 days have not yet passed since their last wellness visit in the prior calendar year.