Get More Help in UtahCoding for Developmental & Mental Health Screening
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Overview
Coding and billing for screening performed in the medical home can help
cover the costs of the work done and the instruments used to monitor for
developmental delays, maternal depression, risky substance use, suicidality, or
mental health disorders. Screening reimbursement is complicated because state and
private insurers may differ on how many screens may be reimbursed during 1 visit or
in 1 year. Some payers contract with participating providers to bundle developmental
or mental health screening with preventive care, or they may direct their providers
to bill differently from the American Medical Association's CPT guidelines. Detailed
coding and billing, even if it does not get paid by Medicaid or the insurer, is
useful to track work value (RVU).
Pearls & Alerts
Importance of coding
Accurate, detailed coding, even for items not currently reimbursable, helps reflect the actual clinical effort and identify codes that may need to be reimbursable in the future to optimize care for children with special health care needs.
Accurate, detailed coding, even for items not currently reimbursable, helps reflect the actual clinical effort and identify codes that may need to be reimbursable in the future to optimize care for children with special health care needs.
ICD-10-CM Codes for Screening
ICD-10-CM codes from A00.0 through T88.9, Z00-Z99 must be used to identify
diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the
encounter/visit. The following ICD-10-CM Z codes are frequently used for
screening.
Z00.1*- Well-child check/Encounter for newborn, infant and child
health examinations, including routine developmental screening.
- Z00.129 - well-child visits >28 days, without abnormal findings
- Z00.121 - well-child visits >28 days, with abnormal findings
- A Z00.1* health exam is always listed first, as the primary reason for the visit.
Z13.3*- Encounter for screening examination for mental
health and behavioral disorders.
You do not need to add Z13.3* as a secondary code to a well-child check when performing routine depression and substance use screens.
If a Z00.1* well-child exam and a Z13.3* behavioral health exam are both reasons for the visit, list Z00.1* first, as the primary code, and Z13.3* as a secondary code.
- Z13.30 …… unspecified
- Z13.31 Encounter for screening for depression
- Z13.32 Encounter for screening for maternal depression (this can be coded in the mother’s chart but not the infant’s)
- Z13.39 Encounter for screening examination for other mental health and behavioral disorders
You do not need to add Z13.3* as a secondary code to a well-child check when performing routine depression and substance use screens.
If a Z00.1* well-child exam and a Z13.3* behavioral health exam are both reasons for the visit, list Z00.1* first, as the primary code, and Z13.3* as a secondary code.
Z13.4*- Encounter for screening for certain
developmental disorders in childhood.
There is no need to add Z13.4* as a secondary code to a well-child check when performing routine developmental and autism screening.
If a Z00.1* well-child exam and a Z13.4* developmental-screening exam are both unique reasons for the visit, list Z00.1* first, as the primary code, and Z13.4* as a secondary code. For example, both codes could be used during a well-child check if additional screening for ADHD or anxiety is administered.
- Z13.40 Encounter for screening for unspecified developmental delays
- Z13.41 Encounter for autism screening
- Z13.42 Encounter for screening for global developmental delays (milestones)
- Z13.49 Encounter for screening for other developmental delays
There is no need to add Z13.4* as a secondary code to a well-child check when performing routine developmental and autism screening.
If a Z00.1* well-child exam and a Z13.4* developmental-screening exam are both unique reasons for the visit, list Z00.1* first, as the primary code, and Z13.4* as a secondary code. For example, both codes could be used during a well-child check if additional screening for ADHD or anxiety is administered.
Z13.89 Encounter for screening for other disorder (when not
listed elsewhere in the ICD-10 codes) – usually not necessary to report in addition
to a well-child exam.
Current Procedural Terminology (CPT)
CPT codes are used to request reimbursement for the
expense of each screening instrument including the scoring and
documentation. Documentation should include the date, patient's name, name and
relationship of the informant (when information is provided by someone other than
the patient), name of the instrument, score, and name and credentials of the
individual administering/scoring the instrument. The physician must
document that he or she reviewed the score in the context of the patient
presentation and discussed the results with the patient/family as part of the
related E/M or preventive service. Associate the CPT code with an
appropriate ICD-10-CM code, often the Z00.12* well-child code.
CPT Code
Examples of Screens
96110 Developmental screening (e.g., developmental
milestone survey, speech and language delay screen, autism
screen)
M-CHAT, ASQ-3rd Edition, PEDS, SWYC
96127 Brief emotional/behavioral assessment (e.g.,
depression inventory, attention-deficit/hyperactivity disorder [ADHD]
scale)
ASQ-SE, SCARED, Vanderbilt, PSC, PHQ-2, PHQ-9 or adolescent
version, Connors
96160 Administration of patient-focused
health risk assessment instrument (e.g., health hazard
appraisal)
CRAFFT, AUDIT, BSTAD, S2BI, DAST-20
96161* Administration of caregiver-focused
health risk assessment instrument (e.g., depression
inventory) for the benefit of the patient
Edinburgh Postnatal Depression Scale (English), PHQ-2, PHQ-9
administered to caregiver during a baby’s visit
Payers vary in their requirements and reimbursements for screening
instruments.
Modifiers 25 and 59
Modifier 25 appends one service with a second, separately
identifiable E/M service. Modifier 25 states that the procedure performed should be
considered separate from the visit. There is no need to use Modifier 25 for routine
screening in a well-child visit.
Modifier 59 indicates a distinct procedural service (non-E/M
service). Documentation should demonstrate the distinction between procedure(s) with
each other and/or the visit to support billing both. Sometimes a modifier 59 might
be required if two of the same type of screens are used during the same visit, but
this can vary by payer.
Coding Examples
The ICD-10-CM codes (reasons for the visit) are listed first, followed by
associated CPT (procedure) codes and modifiers.
Example 1: Well-child Check with Routine Screening and an Ear Infection
During an 18-month, well-child visit, the parent completes an autism
screen and a developmental screen. The clinician reviews the results of both
screens with the family and documents them appropriately in the visit note. The
child also has an ear infection requiring treatment.
CPT Codes
Associated ICD-10-CM Codes
99392*25 Early childhood preventive medicine
services
Z00.121 Well-child check with abnormal findings (primary
diagnosis)
96110 x 2 developmental screens (reimbursement
varies)
Z00.121
99213 distinct E/M service
H66* suppurative otitis media
Example 2: 4 Month Well-child Check with Abnormal Maternal Depression Screen
During a well-child visit for a healthy 4-month-old, the mother
completes a SWYC developmental screen for the infant, which is normal. She also
completes an Edinburgh maternal depression screen, which is abnormal. The
provider spends an additional 10 minutes talking with the mom and contacting the
social worker.
CPT Codes
Associated ICD-10-CM Codes^
99391*25 Infant preventive medicine services
SWYC
Z00.121 Well-child check with abnormal findings (primary
diagnosis)
96110 Developmental screen – Child Development
screening
Z00.121
96161 Caregiver assessment (Edinburgh) Mother Depression
screening
Z00.121
^Do not report Z13.3* (maternal depression codes) as diagnoses in the
baby’s chart; they belong in the maternal record.
The provider is advised not to add time-based billing for the parent
counseling. Refer the parent to her own provider for additional
care.
Example 3: Routine Adolescent Health Check with New Concern for Anxiety
During a well-child visit for an established 17-year-old, the patient
completes a PHQ-9 and a CRAFFT 2.1, both of which are normal. The adolescent
reports feeling anxious in crowds and talking in front of the class at school.
In addition to the routine depression and risky substance use screeners
completed at check-in, the patient also completes a SCARED Version for Child
(anxiety screen), which is abnormal. The provider briefly discusses the results
with the patient and then recommends a follow-up visit focused on anxiety.
CPT Codes
Associated ICD-10-CM Codes
99394*25 adolescent preventive medicine
services
Z00.121 Well-child check with abnormal findings (primary
diagnosis)
96127x2 Brief emotional/behavioral assessment (PHQ-9
Depression) and (SCARED anxiety)
Z00.121
^Note that the likelihood of reimbursement for the 96160 is low
because the 96160 can be considered a component of the 96127 code. Make sure
that the documentation validates that the 96160 is a separate risk
assessment.
Example 4. Screens Reviewed During a Behavioral Health/Medication Management Follow-Up Visit
During a 40-minute visit to follow up an established patient with
previously diagnosed ADHD and anxiety, the clinician discusses the latest
results of the Follow-Up Vanderbilt for Teacher, the Follow-Up Vanderbilt for
Parent (ADHD monitoring instruments), and the GAD-7 anxiety screen completed by
the patient online prior to the visit. Medication adjustments are made as well
as counseling on relaxation exercises.
CPT Codes
Associated ICD-10-CM Codes
99215*25 Time-based E/M (counseling/care coordination
>50% of visit)
F90.2 ADHD combined type (primary
diagnosis)
96127 x 3 Brief emotional/behavioral assessment
F90.2
Example 5. Developmental and Autism Screening Performed During an Unrelated Sick Visit
An established 18-month-old patient presents for an E/M visit for an
ear infection requiring treatment. During the visit, the provider realizes that
the 18-month-old child missed his last well-child check and administers a
developmental screen and an autism screen. The clinician reviews the results
with the family.
CPT Codes
Associated ICD-10-CM Codes
99213*25 E/M services
H66* suppurative otitis media (primary
diagnosis)
96110 x2 Developmental screens
Z134.42 screening for global developmental
delay
Example 6. Positive Depression Screen and Screening for Substance Use During an Unrelated Visit
When you are wrapping up a short visit to assess a rash in a
14-year-old male established patient, his father expresses concerns that he
seems depressed. You administer a Patient Health Questionnaire (PHQ-9/A)
(adolescent version), which is positive for depression, and a Drug Abuse
Screening Test (DAST-10), which is negative for risky substance use. You spend
25 minutes of face-to-face time with the patient and his father reviewing the
screens, prescribing an anti-depressant and providing counseling and care coordination.
CPT Codes
Associated ICD-10-CM Codes
99214 E/M services (counseling/care coordination >50%
of visit, total of 30 minutes)
R21 Rash and other nonspecific skin eruption (primary
diagnosis)
Example 7. Wart Removal Plus New Behavioral Concerns
During a 7-year-old, new patient visit to your clinic for a wart
removal with liquid nitrogen, the family asks how to tell if she might have
ADHD. In 10 minutes, you take a short history of their concerns and describe the
diagnostic process for ADHD. You provide Vanderbilts (ADHD screeners) for them
to complete after the visit and ask them to set up a follow-up visit.
CPT Codes
Associated ICD-10-CM Codes
17110 Destruction of benign lesions other than skin tags
or cutaneous vascular lesions; up to 14 lesions
B07.9 Viral warts, unspecified (primary diagnosis)
99201*25 (new patient, counseling/care coordination
>50% of visit, 10 minutes)
Z73.9 Problem related to life management difficulty,
unspecified
^The 25-modifier is only placed on E/M CPT codes (e.g., the 99201).
Modifier 25 is not considered valid when appended to surgical codes, medical
procedures, diagnostic tests and procedures, etc., so it does not append the
17110 code in this example.
Note that screens were not administered or reviewed during this visit,
so you do not include the screening CPT codes.
Example 8. Subsequent Wart Removal Plus Discussion of Screening Results
At the next visit, you spend 25 minutes reviewing the screens and
making recommendations for treatment of her newly diagnosed ADHD. You also
perform wart removal.
CPT Codes
Associated ICD-10-CM Codes
99214*25 (established patient, counseling/care
coordination >50% of visit, 25 minutes)
F90.0 ADHD, inattentive type
96127 x2 Brief emotional screeners (both Vanderbilts)
F90.0
Resources
Information & Support
Related content on the Portal includes:
For Professionals
Coding Fact Sheets (AAP)
Codes for medical home visits, mental health care, oral health, screening, and more that clinicians can submit to insurance
carriers for payment of medical services; American Academy of Pediatrics.
Coding Resources (AAP)
Books, quick references, and how-to guides for CPT and ICD-10 coding specific to pediatrics; available for purchase from the
American Academy of Pediatrics.
CPT Code for Caregiver-Focused Assessment (AAP)
Codes for reporting the administration and scoring of a patient-centered health risk assessment and a caregiver-focused health
risk assessment; American Academy of Pediatrics.
International Classification of Diseases, 10th Revision (WHO)
ICD-10-CM 2020 codes accessible as PDF and XML files created by the National Center for Health Statistics with authorization
by the World Health Organization.
Coding for Pediatric Preventive Care (AAP) (
2.0 MB)
A 44-page guide to coding for preventive care services as recommended for pediatric care; Bright Futures/American Academy
of Pediatrics.