| ICD-10-CM* |
| Primary Diagnosis |
P04.3 | Newborn (suspected to be) affected by maternal use of alcohol (Excludes fetal Alcohol Syndrome) |
| Q86.0 | Fetal alcohol syndrome (dysmorphic) |
| F06.30 | Mood disorder due to known physiological condition, unspecified |
| P00.4 | Newborn (suspected to be) affected by maternal nutritional disorders |
| P01.9 | Newborn (suspected to be) affected by maternal comlication of pregnancy, unspecified |
| G93.4 | Encephalopathy, other and unspecified (static) |
| G96.8 | Other specified disorders of central nervous system |
G96.9 | Disorder of central nervous system, unspecified |
| Facial Features |
| Q11.2 | Microcephaly |
| R68.89 | Other general symptoms and signs(eg, dysmorphic features) |
| Growth |
| R63.6 | Underweight |
| R63.3 | Feeding difficulties |
| R62.51 | Failure to thrive (child) |
| R62.52 | Short stature (child) |
| Development |
| R62.50 | Lack of expected normal physiological development in childhood, unspecified |
| R62.0 | Delayed milestone in chidhood |
| CNS Abnormality |
| G31.84 | Mild cognitive impairment, so stated |
| F70 | Mild intellectual disabilities |
| F71 | Moderate intellectual disabilities |
| F72 | Severe intellectual disabilities |
| F73 | Profound intellectual disabilities |
| F78 | Intellectual disabilities, Other specified |
| F79 | Intellectual disabilities, Unspecified |
| G92 | Toxic encephalopathy (code first (T51-T65) to identify toxic agent) |
| F43.10 | Post-traumatic stress disorder, unspecified |
| F43.11 | Post-traumatic stress disorder, acute |
| F43.12 | Post-traumatic stress disorder, chronic |
| F94.1 | Reactive attachment disorder of childhood |
| F63.81 | Intermittent explosive disorder |
| F80.1 | Expressive language isorder |
| F80.2 | Mixed receptive-expressive language disorder |
| F81.9 | Developmental disorder of scholastic skills, unspecified |
F89 | Disorder of psychological development, unspecified |
| F90.0 | ADHD, predominantly inaatentive type |
| F90.1 | ADHD, predominantly hyperactive type |
| F90.8 | Attention-deficit hyperactive disorder, other type |
| F81.0 | Specific reading disorder |
| R48.0 | Alexia/dyslexia, NOS |
| F81.0 | Developmental dyslexia |
| F81.0 | Specific reading disorder |
| F81.2 | Mathematics disorder |
| F81.81 | Disorder of written expression |
| R27.0 | Ataxia, unspecified |
| R27.8 | Other lack of coordination |
| R27.9 | Unspecified lack of coordination |
| R48.9 | Symbolic dyfunction, unspecified |
| R48.0 | Alexia/dyslexia, NOS |
| R48.1 | Agnosia |
| R48.2 | Apraxia |
| R48.3 | Visual agnosia |
| R48.8 | Other symbolic dysfunctions |
| R41.840 | Attention and concentration deficit (Excludes attention deflicit disorder) |
| R41.841 | Cognitive communication deficit |
| R41.842 | Visuospatial deficit |
| R41.843 | Psychomotor deficit |
| R41.844 | Frontal lobe and executive function deficit |
| R41.89 | Other symptoms and signs involving cognitive functions and awareness |
| F81.9 | Developmental disorder of scholastic skills, unspecified |
| R46.89 | Other symptoms and signs involving appearance and behavior |
| R48.9 | Nonpsychotic mental disorder, unspecified |
| Z03.89 | Encounter for observation for other suspected diseases and conditions ruled out (eg, mental health)_ |
| Secondary Diagnosis |
| G40- | Epilepsy and recurrent seizures (Code will require 5th or 6th digit) |
| G80- | Cerebral Palsy (code will require a 4th digit) |
| P04- | Newborn (suspected to be) affected by noxious substances transmitted vis placenta or breast milk (Code requires 4th or 5th digit) |
| G47.00 | Insomnia, unspecified |
T74-
T76-
And
Y07.11
Y07.12
Y07.13
Y07.14
Y07.420
Y07.421
T74.4XX
| Child abuse, neglect and other maltreatment; confirmed (code perpetrator if known)
Suspected (code perpetrator if known) 4th and 5th Digits
02 - Child neglect or abandonment
12 - Child physical abuse
22 - Child sexual abuse
32 - Child psychological abuse
92- Unspecified child maltreatment
7th Digit
A - initial encounter
D - subsequent encounter
S - sequela
Perpetrator
Biological father
Biological mother
Adoptive father
Adoptive mother
Foster father
Foster mother
Shaken infant syndrome (Requires 7th digit to define encounter- see above)
|
| Z71.89 | Other specified counseling |
| Z62.820 | Parent-biological child conflict |
Z62.821 | Parent-adopted child coflict |
| Z62.822 | Parent-foster child conflict |
Z71.41 | Alcohol abuse counseling and surveillance of alcoholic |
| Z71.51 | Drug abuse counseling and surveillance of drug abuser |
| Z55.3 | Underachievement in school |
| Z55.8 | Problems related to school and literacy |
| Z13.89 | Encounter for screening for other disorder |
| Z13.4 | Encounter for screening for certain developmental disorders in childhood |
| Z13.4 | Encounter for screening for certain developmental disorders in childhood |
| Z13.89 | Encounter for screening for other disorder |
| Z13.858 | Encounter for screening for other nervous system disorders |
Evaluation and Management Current Procedural Terminology
(CPT®) Codes |
| 99201-99205 | New** patient office visit |
| 99211-99215 | Established out-patient office visit |
| 99241-99245 | Consultation out-patient (new or established) |
| Prolonged Services
|
+99354
+99355
99358
+99359
+99415
+99416 | Prolonged services w/ patient; initial 30-74 min. (report in addition to time-based E/M)
Each additional 30 minutes over 74 min. (report with 99354)
Prolonged services, before/after visit, patient/family not present; up to 60 min.
Each 30 minutes after 60 min. (report with 99358)
Prolonged clinical staff services; initial 45-74 minutes (report in addition to time-based E/M)
Each additional 30 minutes (report with 99416) |
| Modifiers | |
25
| Significant, separately identifiable E/M service by same physician on day of procedure |
| 59 | Distinct procedural service |
| 76 | Repeat procedure or service by the same physician |
EPSDT Codes
(None of the EPSDT codes should require prior authorization) |
Z00.110 Z00.111 | Health examination for newborn under 8 days old Health examination for newborn 8 to 28 days old |
Z00.121 Z00.129 | Encounter for routine child health examination with abnormal findings ( use additional code to identify abnormal findings) Encounter for routine child health examination without abnormal findings |
Z00.00 Z00.01 | Encounter for general adult medical examination without abnormal findings Encounter for general adult medical examination with abnormal findings (use additional code to identify abnormal findings) |
| Z02.83 | Encounter for blood-alcohol and blood-drug test |
| Z02.9 | Encounter for administrative examinations, unspecified |
| Preventive Service CPT Codes |
| 99381-5 | Preventive EPSDT visits for new** patients by age |
| 99391-5 | Preventive EPSDT visits for established patients by age |
| Non-Face-to-Face Services |
99490
99487
| Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:- multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
- chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
- comprehensive care plan established, implemented, revised, or monitored.
Complex chronic care management services, with the following required elements: - multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
- chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
- establishment or substantial revision of a comprehensive care plan;
- moderate or high complexity medical decision making;
- 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
|
| +99489 | Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (Use in conjunction with 99487) |
Complex chronic care services are reported by the physician or qualified health care professional who provides or oversees the management and coordination of all of the medical, psychosocial, and daily living needs of a patient with a chronic medical condition. Typical pediatric patients- receive three or more therapeutic interventions (eg, medications, nutritional support, respiratory therapy)
- have two or more chronic continuous or episodic health conditions expected to last at least 12 months (or until death of the patient) and places the patient at significant risk of death, acute exacerbation or decompensation, or functional decline
- commonly require the coordination of a number of specialties and services.
|
| 99495 | Transitional care management (TCM) services with the following required elements:- Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
- Medical decision-making of at least moderate complexity during the service period
- Face-to-face visit, within 14 calendar days of discharge
|
| 99486 | TCM services with the following required elements:- Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
- Medical decision-making of high complexity during the service period
- Face-to-face visit, within 7 calendar days of discharge
|
| 99367 | Medical Team Conference w/outpatient or family >30 minutes; physician or other qualified healthcare professional |
| Other Services |
96110
| Developmental screening (per standardized instrument)
|
| 96111 | Developmental testing |
| 96116 | Neurobehavioral Status Exam (per hour) |
| 96125 | Standardized cognitive performance testing, per hour |
| 96127 | Standardized emotional/behavioral assessment (eg, ADHD, depression) |
| 99420 | Health risk assessment instrument |