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

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 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

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

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.

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.

Payers vary in their requirements and reimbursements for screening instruments.

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.

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

Example 2: 4 Month Well-child Check with Abnormal Maternal Depression Screen

Example 3: Routine Adolescent Health Check with New Concern for Anxiety

Example 4. Screens Reviewed During a Behavioral Health/Medication Management Follow-Up Visit

Example 5. Developmental and Autism Screening Performed During an Unrelated Sick Visit

Example 6. Positive Depression Screen and Screening for Substance Use During an Unrelated Visit

Example 7. Wart Removal Plus New Behavioral Concerns

Example 8. Subsequent Wart Removal Plus Discussion of Screening Results