Optimal Clinical Coding for CYSHCN

Overview

Though electronic medical records have simplified diagnostic coding for many, understanding all available codes may support better billing and compensation, particularly for services provided to children and youth with special health care needs (CYSHCN). Some codes may not be recognized or compensated by some insurers, but codes that are used appropriately are more likely to gain recognition and compensation over time. In larger organizations, coding for all services rendered may result in additional work relative value units (WRVU) credited to clinicians, even if they do not result in third-party payment.

International Classification of Diseases (ICD-10) Coding

Diagnosis coding is based on the ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification), which includes codes that describe diagnoses, conditions, signs, and symptoms. It also has codes for injuries, poisoning, and other external causes of morbidity (such as accidents and exposures) and factors influencing health status and contact with health services. The Centers for Disease Control and Prevention (CDC) maintain an updated, free version of the International Classification of Diseases, 10th Revision (WHO); ICD10Data.com offers a free, user-friendly way to search for codes.
ICD-10 code books are organized in two ways—alphabetically by diagnosis (Index) and numerically by code (Tabular List). In general, first look in the alphabetic list for the diagnosis, symptom, etc. Then look up that code in the tabular list to confirm its accuracy and to peruse subcodes and surrounding codes to ensure appropriate specificity and level of detail.
The most specific code(s) possible should be used.
Example
Q20-28 Congenital malformations of the circulatory system
  • Q21 Congenital malformations of cardiac septa
    • Q21.3 Tetralogy of Fallot
Example
H65-H75 Diseases of middle ear and mastoid
  • H66 Suppurative and unspecified otitis media
    • H66.00 Acute suppurative otitis media without spontaneous rupture of eardrum
      • H66.004 Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear

ICD-10 Diagnostic Coding for Unknown Diagnoses

When a diagnosis is not known, presenting signs or symptoms may be the most accurate way to describe the reason for providing the service. Codes should not be used for conditions to be "ruled out" or that are "possible" or "probable."
Examples of presenting signs or symptoms or reason for the visit include:
  • Fever [R50.9]
  • Hemoglobinuria [R82.3]
  • Macrocephaly [Q75.3]
  • Low-birth weight, 1500-1999 grams [P07.17]
  • Routine child health check with abnormal findings [Z00.121]
  • Fall from non-moving wheelchair, initial encounter [W05.0XXA]

ICD-10 Diagnostic Coding for Social Determinants of Health

Social determinants of health (SDOH) often impact the complexity of caring for children and youth with special health care needs and increase the risk of morbidity and mortality in those patients. With the 2021 guidelines for office-based evaluation and management (E/M), presence of one or more SDOH that result in greater risk may warrant coding for a higher level of E/M service (see below under Current Procedural Terminology (CPT) Coding). Documenting the presence and impact of the SDOH and using appropriate ICD-10 codes as secondary is essential to support the higher service level. Many ICD-10 codes may be relevant; below are some examples. [AAP: 2021]
Social Determinant ICD-10-CM code/description
Abuse (history of) Z62.810 Personal history of physical and sexual abuse in childhood
Z62.811 Psychological abuse in childhood
Z62.812 Neglect in childhood
Z62819 Unspecified abuse in childhood
Economic difficulties Z59.5 Extreme poverty
Z59.6 Low income
Z59.7 Insufficient social insurance and welfare support
Z91.120 Patient’s intentional underdosing of medication regiment due to financial hardship
Education Z55.1 Schooling unavailable and unattainable
Z55.3 Underachievement in school
Z55.4 Educational maladjustment and discord with teachers and classmates
Environmentally compromised housing Z77.011 Contact with and (suspected) exposure to lead
Z77.1 … to other environmental pollution
Family/primary support group issues (relationship) Z63.31 Absence of family member due to military deployment
Z63.4 Disappearance and death of family member
Z63.5 Disruption of family by separation and divorce
Z63.71 Stress on family due to return of family member from military deployment
Z63.79 Other stressful life events affecting family and household Z63.0 Problems in relationship with spouse or partner
Food insecurity Z59.4 Lack of adequate food
Parent/sibling-child issues Z62.0 Inadequate parental supervision and control
Z62.3 Hostility toward and scapegoating of child
Z62.6 Inappropriate (excessive) parental pressure
Z62.820 Parent-biological child conflict
Z62.821 Parent-adopted child conflict
Z62.822 Parent-foster child conflict
Social issues Z60.0 Problems of adjustment to life-cycle transitions
Z60.3 Acculturation difficulty
Z60.4 Social isolation, exclusion and rejection
Z60.5 Target of (perceived) adverse discrimination and persecution
Substance use Z63.72 Alcoholism and drug addiction in family
Z71.41 Alcohol abuse counseling and surveillance of alcoholic
Z71.42 Counseling for family member of alcoholic
Z71.51 Drug abuse counseling and surveillance of drug abuser
Z71.52 Counseling for family member of drug abuser
Transportation issues Z79.89 Other specified risk factors, not elsewhere classified
Upbringing issues Z62.21 Child in welfare custody
Z62.22 Institutional upbringing
Z62.29 Other upbringing away from parents
Z62.898 Other specified problems related to upbringing
Z62.9 Problem related to upbringing, unspecified
(Table adapted from [AAP: 2021]. The table does not include all potentially relevant SDOH; consult an ICD-10-CM manual or ICD10Data.com for additional codes.)

Current Procedural Terminology (CPT) Coding

The codes used to bill for medical services are described by the CPT (Current Procedural Terminology) , published by the American Medical Association, and not available in a free version. It includes various categories and types of codes, but we will focus on Category 1 codes that are used for evaluation and management services in outpatient settings. Most of the codes described below apply to services provided by physicians. Some include services provided by other qualified health care professionals, defined as “individuals who are qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who perform professional services within his/her scope of practice and independently reports that professional service.” This group includes nurse practitioners, certified nurse specialists, physician assistants, clinical social workers, physical therapists, and others. Some codes also include services provided by clinical staff under the supervision of a physician or another qualified health care professional.

Evaluation and Management Services

As of 2021, selection of evaluation and management (E/M) codes (99202-99205, 99212-99215, and 99XXX) is based on whether the patient is new or established with the practice, and the complexity of medical decision making (MDM) or the total time on the day of the encounter. 99211 remains available for visits that do not require physician presence, such as RN visits, specimen collection, etc.
Encounter time, specified in distinct ranges that vary by new or established patient, now includes now includes nonface-to-face work on the day of the encounter and may apply whether or not counseling/coordination of care predominated during the visit. Activities that may contribute to the time-related coding include:
  • Reviewing tests in visit preparation
  • Counseling or educating a patient, family, or caregiver (including prolonged discussion related to misperceptions, information gathered from the internet, etc.)
  • Reporting test results by phone
  • Ordering medications, tests, or procedures
  • Documenting related work at home
Time increments are:
New Patients
99202 15-29 min.
99203 30-44 min.
99204 45-59 min.
99205 60-74 min.
99XXX ≥ 75 min.
Established Patients
99212 10-19 min.
99213 20-29 min.
99214 30-39 min.
99215 40-54 min.
99XXX ≥ 55 min.
The elements of MDM that contribute to it being straightforward, low, moderate, or high complexity include:
  • The number and complexity of problems addressed; it is no longer necessary to document all of a patient’s diagnoses, just those addressed during the encounter
  • The amount and complexity of data reviewed and analyzed; it is no longer necessary to include irrelevant data in the encounter record
  • Risk of complications or morbidity, including social determinants of health and reasons behind decisions to not intervene in some way
When preventive medicine services (“well-child visits”) for CYSHCN significantly exceed the usual service provided for such a visit, an office visit code with a -25 modifier may be added. For example, billing a preventive medicine visit code (99381-99397) plus an office visit code with the modifier (e.g., 99213-25 or 99214-25) would account for the added service addressing the child’s spasticity, seizure disorder, and feeding problems.
Guidelines for documentation (and everything else related to Medicare and Medicaid billing) can be found on the Center for Medicare & Medicaid Services (CMS) website at CMS Online Manual System. The Physician Fee Schedule Look-Up Tool (CMS) offers information on each CPT (aka Healthcare Common Procedure Coding System, HCPCS) code, including assigned relative value units (RVUs), Medicare payment amounts (both national and by specific localities), and more. Acceptance of codes and payment by Medicaid and commercial insurance plans will vary by state and other factors.

Medical Home Services

Over the past few years, CPT has added codes for several special services provided by Medical Homes, including non-face-to-face services, home visits, care plan oversight, team conferences, transition to adult care management, and complex chronic care management. Deciding whether to use new codes (and some older codes, such as telephone services) is complicated by questions about their acceptance or compensation by a practice’s range of payers and the potential consequences for patients/families, including triggering unexpected co-payments or full payment for those with high deductibles. Over time, most codes accepted by Medicare are accepted by other payors, which may take longer if the codes are rarely submitted. Those considerations, along with discussions with key payers and patients’ parents, should drive development of a thoughtful strategy for supporting the provision of services for CYSHCN. Informing parents prior to use of codes for which insurance coverage is not certain can avoid unwelcome surprises and angry reactions if a billed code is rejected.
2021 Coding and Payment for Transition from Pediatric to Adult Health Care (PDF Document 509 KB) from Got Transition (MCHB/NAAAH) provides an excellent overview of the CPT codes relevant to outpatient care of CYSHCN. It also offers detailed descriptions of the codes and their associated RVUs and Medicare payment amounts. Though the document was prepared to support clinicians transitioning patients and includes transition-specific scenarios, the codes and their descriptions/payments apply to all ages. Before using any unfamiliar codes discussed below, we suggest consulting the CPT (Current Procedural Terminology) or a Certified Coding Specialist to ensure detailed compliance.

Care Plan Oversight Services

These apply to physician supervision of a patient (who is not present during the service) in a home, domiciliary, or rest home requiring complex and multi-disciplinary care involving regular physician development/revision of care plans, review of status reports and related laboratory and other studies, communication with relevant other providers, family members, surrogate decision-makers, and/or caregivers, and integration of new information into the care plan or adjustment of medical therapy.
  • The appropriate code is based on total time within a calendar month: 99339 (15-29 minutes) or 99340 (30 minutes or more).

Home Services

These apply to E/M services provided in a private residence, temporary lodging, or short-term accommodation. The CPT codes, like those for E/M services, are based on new vs. established patient and the components of care provided. “Typical” visit durations are suggested, allowing time-based coding when care coordination/counseling comprise more than 50% of the visit time. The codes include:
  • For new patients, 99341-99345, with typical duration from 20 to 75 minutes
  • For established patients, 99347-99350, with typical duration from 15 to 60 minutes
These codes are not included in Transition to Adult Health Care Coding (AAP & GotTransition) (PDF Document 426 KB), mentioned above.

Prolonged Services With Direct Patient Contact

These CPT codes are used, separately and in addition to the primary E/M code, when prolonged services involving direct patient contact are provided by a physician or other qualified health care professional for at least 30 minutes beyond the typical time for the primary service. As of 2021, these codes can no longer be used with office visit codes (99202-99215). The codes report the total duration of face-to-face time spent on a given date providing prolonged service, even if that service is not continuous.
  • 99354 is used for the first “hour” (30-74 minutes) of prolonged services; this code may be used only once for a given date.
  • 99355 is used for each additional 30 minutes beyond the first hour (total of 75-104 minutes, 105-134 minutes, etc.) on a given date.

Prolonged Services Without Direct Patient Contact

These are used to report prolonged, non-face-to-face services related to a recent or upcoming E/M service but not provided as part of that service/visit. As of 2021, these codes can no longer be used with office visit codes (99202-99215). The services must be performed by the billing clinician on a single day, but the time spent need not be continuous. Such services might include review of records, writing a summary or report, etc.
  • 99358 is used for the first “hour” (30-74 minutes) of prolonged services; this code may be used only once for a given date.
  • 99359 is used for each additional 30 minutes beyond the first hour (total of 75-104 minutes, 105-134 minutes, etc.) on a given date.
Prolonged service codes are reported for time spent by the billing clinician only, not for clinical staff. They cannot be used for time spent related to services for which no typical time is specified, nor can they be reported during the same service period as complex chronic care management (CCM) services or transitional care management (TCM) services. Prolonged Services Codes: Criteria for Use (AAP) offers further explanation, tips, and vignettes.

Prolonged Clinical Staff Services With Physician or Other Qualified Health Care Professional Supervision

These are reported, in addition to the designated E/M service, when a prolonged E/M service is provided that involves prolonged clinical staff face-to-face time beyond that typical for the service while the physician or qualified health care professional is present to provide direct supervision. The time reported is the total duration spent by clinical staff on the date of the designated E/M service. These codes may be reported for no more than two simultaneous patients.
  • 99415 is used for the first hour of prolonged clinical staff service
  • 99416 is used for each additional 30 minutes beyond the first hour

COVID-19 Vaccine and Administration Services

CPT Code Description
91300 Pfizer-BioNTech COVID-19 Vaccine Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use. (Report 91300 with administration codes 0001A, 0002A)
0001A Pfizer-BioNTech COVID-19 Vaccine Administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose
0002A - administration of second dose of Pfizer-BioNTech vaccine
91301 Moderna COVID-19 Vaccine Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use. (Report 91301 with administration codes 0011A, 0012A)
0011A Moderna COVID-19 Vaccine Administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose
0012A - administration of second dose of Moderna vaccine

COVID-19 Testing

CPT Code Description
86328 Immunoassay for infectious agent antibody(s), qualitative or semiquantitative, single-step method (e.g., reagent strip);
86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) (Coronavirus disease [COVID19]); screen
86409 - titer
86413 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2)(Coronavirus disease [COVID-19]) antibody, quantitative
86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 Coronavirus 2) (Coronavirus disease [COVID-19])
87426 Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19])
87428 Multiplex infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B
87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
87636 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique
87637 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique
87811 Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

Medical Team Conferences

These are used for face-to-face participation of 3 or more qualified health care professionals from different specialties/disciplines who are providing care to the patient, with or without the presence of the patient, family members, surrogate decision-makers, or community agencies. Reporting clinicians must have provided face-to-face services to the patient in the previous 60 days. The time reported includes only the time spent discussing the patient and not record keeping or report generation.
  • 99366 is used by nonphysician qualified health care professionals for participation in conferences of 30 minutes or more, with patient and/or family present.
  • 99367 is used by physicians for participation in conferences of 30 minutes or more, with the patient or family not present. (Physicians should use E/M codes to report time in team conferences with the patient and/or family present.)
  • 99368 is used by nonphysician qualified health care professionals for participation in conferences of 30 minutes or more, with patient or family not present.

General Behavioral Health Integration Care Management

99484 is used by the supervising physician or other qualified health care professional to report care management services (face-to-face or non-face-to-face) performed by clinical staff for a patient with a behavioral health/substance use condition. The reported service must have required 20 minutes or more in a calendar month, and a treatment plan is required. The reporting professional must have an ongoing relationship with the patient.

Care Management Services

These are used for management and support services provided by a physician or other qualified health care professional or by clinical staff under the professional’s direction to a patient residing at home or in a domiciliary, rest home, or assisted living facility and who has 2 or more chronic or episodic conditions expected to last 12 months or longer and that place the patient at significant risk of death, acute exacerbation/decomposition or functional decline. Services include those related to developing and managing a care plan, coordinating care of other professionals or agencies, and educating patients/families about the condition. A comprehensive care plan must be documented and shared with the patient and/or caregiver, identify individuals responsible for each intervention, and include requirement for periodic review and, if needed, revision of the plan.
  • 99487 is used for establishment/substantial revision of a comprehensive care plan involving moderate-high complexity medical decision-making requiring 60 minutes of clinical staff time in a calendar month
  • 99489 is used to report each additional 30 minutes required in a calendar month
  • 99490 is used for establishment, implementation, revision, or monitoring of a comprehensive care plan requiring at least 20 minutes of clinical staff time in a calendar month
  • 99491 is used for establishment, implementation, revision, or monitoring of a comprehensive care plan requiring at least 30 minutes of physician or other qualified health care professional time in a calendar month
The time reported for 99487, 99489, and 99490 includes face‐to‐face and non‐face‐to‐face time spent by clinical staff in communicating with the patient and/or family, caregivers, other professionals, and agencies; creating, revising, documenting, and implementing the care plan; or teaching self‐management during the month. Because the reporting requirements are complex, we recommend reviewing them in detail or consulting a coding specialist.

Principal Care Management (PCM) Services

Using these codes, practices may bill for chronic care management (CCM) services provided to patients with one serious chronic condition. These codes may not be used simultaneously for the same patient with other care management services. Conditions must include these elements: with the following elements: one complex chronic condition lasting at least three months, which is the focus of the care plan; the condition is of sufficient severity to place the patient at risk of hospitalization or to have been the cause of a recent hospitalization; the condition requires development or revision of a disease-specific care plan; the condition requires frequent adjustments in the medication regimen; and/or the management of the condition is unusually complex due to comorbidities.
  • G2064. CCM for a single high-risk disease (i.e., PCM) at least 30 minutes of physician or other qualified health care professional time per calendar month
  • G2065. CCM for a single high-risk disease, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month

Transitional Care Management Services

These are services for new or established patients whose medical and/or psychosocial problems require moderate or high complexity medical decision-making during transition from an inpatient or other facility-based care setting to the patient’s home, domiciliary, rest home, or assisted living setting. The service period comprises the 29 days beginning on the date of discharge. Services include initial contact, a face-to-face visit, and medication reconciliation in combination with non-face-to-face services provided by the physician, other qualified health care professional, and/or licensed clinical staff under the professional’s direction.
  • 99495 includes communication (direct contact, telephone, electronic) with the patient/caregiver within 2 business days and a face‐to‐face visit within 14 calendar days of discharge and medical decision‐making of at least moderate complexity
  • 99496 includes communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days, a face‐to‐face visit within 7 calendar days of discharge, and medical decision‐making of high complexity
Because the reporting requirements are complex, we recommend reviewing them in detail or consulting a coding specialist.

Telephone Services

These comprise non-face-to-face E/M services provided by a physician or other qualified health care professional by phone to an established patient or their guardian and that are not related to an E/M service provided within the previous 7 days and do not lead to such a service within 24 hours or the soonest available appointment.
  • 99441 involves 5-10 minutes of medical discussion
  • 99442 involves 11-20 minutes of medical discussion
  • 99443 involves 21-30 minutes of medical discussion

Online Medical Evaluation

  • 99421. Online digital E/M service, for an established patient, 5-10 minutes cumulative time over up to seven days
  • 99422. Online digital E/M service, for an established patient, 11-20 minutes cumulative time over up to seven days
  • 99423. Online digital E/M service, for an established patient, 21 or more minutes cumulative time over up to seven days
If an E/M visit including telemedicine happens within seven days of the initiation of the online digital E/M service, you can add it on to the face-to-face visit only. However, if the telehealth visit is due to another problem, then a separate report is necessary.

Interprofessional Telephone/Internet/Electronic Health Record Consultations

These are assessment and management services provided by a consultative physician to the patient’s treating/requesting physician or other qualified health care professional via telephone, the internet, or electronic health record and include a verbal and written report.
  • 99446 involves 5-10 minutes of medical consultative discussion and review
  • 99447 involves 11-20 minutes of medical consultative discussion and review
  • 99448 involves 21-30 minutes of medical consultative discussion and review
  • 99449 involves 31 minutes or more of medical consultative discussion and review

Education and Training for Patient Self-Management

These codes are used by nonphysician qualified health care professionals for provision of prescribed education and training for patient self-management using a standard curriculum, face-to-face with the patient and/or caregiver/family. Codes are used for each 30 minutes with:
  • 98960 – an individual patient
  • 98961 – 2-4 patients
  • 98962 – 5-8 patients

Resources

Information & Support

For Professionals

Medical Home Resources (AAP)
An in-depth look at the medical home model and how to implement it. Includes information about quality improvement, maintenance of certification activities to improve your medical home, and financing and payment resources; 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.

2021 Coding and Payment for Transition from Pediatric to Adult Health Care (PDF Document 509 KB)
Thirty-three page booklet of CPT coding options for the provision of transition-related services; from Got Transition and the American Academy of Pediatrics.

CPT (Current Procedural Terminology)
Link to the American Medical Association Store where the current version of the CPT can be purchased in hardcopy.

ICD10Data.com
Free, user-friendly reference website that contains all of the official American ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) medical billing codes.

Physician Fee Schedule Look-Up Tool (CMS)
Offers information on each CPT (aka Healthcare Common Procedure Coding System, HCPCS) code, including assigned relative value units (RVUs), payment amounts (both national and by specific localities) and more; from the Centers for Medicare and Medicaid Services (CMS)

Authors & Reviewers

Initial publication: September 2008; last update/revision: January 2021
Current Authors and Reviewers:
Author: Chuck Norlin, MD
Contributing Author: Jason Fox, MPA/MHA
Authoring history

Page Bibliography

AAP Division of Health Care Finance.
Use ICD-10-CM codes when social determinant of health identified.
American Academy of Pediatrics; (2021) https://www.aappublications.org/news/2021/01/01/coding010121. Accessed on 1/21/2021.