Coding for Developmental & Mental Health Screening

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).

Other Names & Coding

Billing and coding for developmental and/or autism screening
Billing and coding for behavioral health (ADHD, anxiety, depression) screening
Billing and coding for caregiver depression screening
Billing and coding for substance abuse screening

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.

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.
  • 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.
  • 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
Z13.39 Encounter for screening examination for other mental health and behavioral disorders
96160*59 Patient-focused health risk assessment instrument (CRAFFT Health Hazard/Alcohol use)^ 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
F40.10 Social anxiety disorder

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)
Z71.89 Other specified counseling
96127 Brief emotional screener (PHQ-9/A) Z13.30 Encounter for mental health and behavioral screening
F32.9 Major depressive disorder, single episode
96160 Health risk assessment (DAST-10) Z13.30

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
Z13.39 Encounter for screening examination for other mental health and behavioral disorders
17110 Destruction of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions B07.9 Viral warts, unspecified (primary diagnosis)

Resources

Information & Support

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 Publications (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) (PDF Document 2.0 MB)
A 44-page guide to coding for preventive care services as recommended for pediatric care; Bright Futures/American Academy of Pediatrics.

Authors & Reviewers

Initial publication: October 2019; last update/revision: October 2019
Current Authors and Reviewers:
Author: Jennifer Goldman-Luthy, MD, MRP, FAAP
Reviewers: Jason Fox, MPA/MHA
Andrea Reeder, MBA, CPC