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Trauma Coding Fact Sheet

Updated 1/1/2016

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The following are coding tips for evaluations involving screening and anticipatory guidance related to trauma and other mental health/developmental concerns.   

Physician Evaluation & Management Services


99201 Office or other outpatient visit, new patient; self limited or minor problem, 10 min.
99202 ​    low to ​​moderate severity problem, 20 min.
99203     modera​​te severity problem, 30 min.
99204     moderate to high severity problem, 45 min.
99205      high severity problem, 60 min.

A new patient is one who has not received any professional services face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s) from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. (CPT 2014 Professional Edition, American Medical Association, page 4).

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99211  Office or other outpatient visit, new patient; self limited or minor problem, 10 min. Office or other outpatient vis​it, established patient; minimal problem, 5 min.
99212       self limited or minor problem, 10 min.
99213       low to moderate severity problem, 15 min.
99214       moderate severity problem, 25 min.
99215       moderate to high severity problem, 40 min.
+99354 Prolonged physician services in office or other outpatient setting, with direct patient contact; first hour (use in conjunction with time-based codes 99201-99215, 99241-99245, 99301-99350)
+99355each additional 30 min. (use in conjunction with 99354)


+Designated add-on codes

  • Used when a physician provides prolonged services beyond the usual service (ie, beyond the typical time).
  • Time spent does not have to be continuous.
  • Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

Reporting E/M services using "Time"

  • When counseling or coordination of care dominates (more than 50%) the physician/patient or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. 
  • This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record. 
  • For coding purposes, face-to-face time for these services is defined as only that time that the physician spends face-to-face with the patient and/or family. This includes the time in which the physician performs such tasks as obtaining a history, performing an examination, and counseling the patient. 
  • When codes are ranked in sequential typical times (such as for the office-based E/M services or consultation codes) and the actual time is between 2 typical times, the code with the typical time closest to the actual time is used. 
  • Prolonged services can only be added to codes with listed typical times such as the ones listed above. In order to report prolonged services the reporting provider must spend a minimum of 30 minutes beyond the typical time listed in the code level being reported. When reporting outpatient prolonged services only count face-to-face time with the reporting provider. When reporting inpatient or observation prolonged services you can count face-to-face time, as well as unit/floor time spent on the patient's care.  However, if the reporting provider is reporting their service based on time (ie, counseling/coordinating care dominate) and not key components, then prolonged services cannot be reported unless the provider reaches 30 minutes beyond the listed typical time in the highest code in the set (eg, 99205, 99226, 99223). It is important that time is clearly noted in the patient's chart. For clinical staff prolonged services, refer to the CPT manual. 
  • Example: A physician sees an established patient in the office to discuss the current asthma medication treatment plan the patient was placed on. The total face-to-face time was 22 minutes, of which 15 minutes was spent in counseling the mom and patient. Because more than 50% of the total time was spent in counseling, the physician would report the E/M service based on time. The physician would report a 99214 instead of a 99213 because the total face-to-face time was closer to a 99214 (25 minutes) than a 99213 (15 minutes).

Preventive Medicine Service Codes

  • To report the appropriate preventive medicine service code, first determine if the patient qualifies as new or established (defined in the next 2 sections), then select the appropriate code within the new or established code family based on patient age.
  • Preventive medicine service codes are not time-based; therefore, time spent during the visit is not relevant in selecting the appropriate code.
  • If an illness or abnormality is encountered or a preexisting problem is addressed in the process of performing the preventive medicine service, and if the illness, abnormality, or problem is significant enough to require additional work to perform the key components of a problem-oriented evaluation and management (E/M) service (history, physical examination, medical decision-making), the appropriate office or other outpatient service code (99201–99215) should be reported in addition to the preventive medicine service code. Modifier 25 should be appended to the office or other outpatient service code to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service.
  • An insignificant or trivial illness, abnormality, or problem encountered in the process of performing the preventive medicine service that does not require additional work and performance of the key components of a problem-oriented E/M service should not be reported.
  • The comprehensive nature of the preventive medicine service codes reflects an age- and gender-appropriate history and physical examination and is not synonymous with the comprehensive examination required for some other E/M codes (eg, 99204, 99205, 99215).
  • Immunizations and ancillary studies involving laboratory, radiology, or other procedures, or screening tests (eg, vision and hearing screening) identified with a specific CPT code, are reported separately from the preventive medicine service code.

New Patients                                                                 

99381  Infant (younger than 1 year)   
99382Early ​childhood (age 1–4 years) 
99383Late childh​ood (age 5–11 years)  
99384 Adolescent (age 12–17 years)  
9938518 years or older​


Established Patients                                                    

99391 Infant (younger than 1 year)   
99392 Ea​rly childhood (age 1–4 years)  
99393Late childhood (age 5–11 years)  
99394 Adolescent (age 12–17 years)
99395 18 y​ears or older  


Screening and Assessment for Developmental and Emotional/Behavioral Issues

96110  Developmental screening (eg, developmental milestone survey, speech and language delay screen), w​ith scoring and documentation, per standardized instrument​
96127Brief em​otional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument 

Physician Non-Face-to-Face Services

  99358Prolonged E/M services before or after direct patient care; first hour.             Note: This code is no longer an "add-on" service and can be reported alone.
+99359each ad​ditional 30 min.   (Use in conjunction with 99358)
99367Medical team conference by physician with interdisciplinary team of healthcare professionals, patient and/or family not present, 30 minutes or more​

Care Management Services:


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:

mu​ltiple (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.          

Do not report 99490 for chronic care management services that do not take a minimum of 20 minutes in a calendar month.

99487Complex chronic care management services;
  • multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
  • chronic cond​itions 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.

    Do not report 99487 for chronic care management services that do not take a minimum of 60 minutes in a calendar month.



25   Significant and separately identifiable E/M service from another proced​​​ure or service

59   Distinc​t procedural service from another non-E/M service

Commonly Reported ICD-10-CM Codes When Caring For Youth Who Have Experienced Trauma​

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Codes

  • Use as many diagnosis codes that apply to document the patient's complexity and report the patient's symptoms and/or adverse environmental circumstances.
  • Once a definitive diagnosis is established, report the appropriate definitive diagnosis code(s) as the primary code, plus any other symptoms that the patient is exhibiting as secondary diagnoses that are not part of the usual disease course or are considered incidental.
  • ICD-10-CM codes are only valid on or after October 1, 2015.
ICD-10-CM ​Child Abuse and Neglect



Child maltreatment, confirmed, unspecified

Child maltreatment, suspected, unspecified  





Encounter for exam and observation

       following  alleged child physical abuse


Encounter for exam and observation

      following  alleged child rape (ruled-out)



Child psychological abuse, confirmed

Child psychological abuse, suspected

Z63.32Other absence of family member
Z62.21Child in welfare (foster care) custody

Other specified problems related to primary

support group



Child neglect or abandonment, confirmed

Child neglect or abandonment, suspected



Child physical abuse, confirmed

Child physical abuse, suspected



Child sexual abuse, confirmed

Child sexual abuse, suspected

​Codes T74 and T76 require a 7th character to complete the code. The 7th character identifies the type of encounter. Report the appropriate 7th character as follows:  A=initial/active care;  D=subsequent care; S=sequela
Physical Symptoms
K59.00Constipation, unspecified
R68.89Other signs/symptoms (Dysmorphic features)
R15.9Fecal incontinence NOS
R32Enuresis, NOS
R62.51Failure to thrive (Child)
R63.3Feeding difficulties


Newborn (suspected to be) affected by maternal use of alcohol

Q86.0Fetal alcohol syndrome (dysmorphic)
E44.1Mild protein-calorie malnutrition
E44.0Moderate protein-calorie malnutrition
E45Nutritional stunting/growth restriction


Extreme immaturity of newborn, unspec wks of gestation

P07.21Gestational age less than 23 completed wks
P07.22Gestational age 23 completed weeks
P07.23Gestational age 24 completed weeks
P07.24Gestational age 25 completed weeks
P07.25Gestational age 26 completed weeks
P07.26Gestational age 27 completed weeks
P07.30​Preterm newborn, unspec weeks of gestation
P07.31Gestational age 28 completed weeks
P07.32Gestational age 29 completed weeks
P07.33Gestational age 30 completed weeks
P07.34Gestational age 31 completed weeks
P07.35Gestational age 32 completed weeks
P07.36Gestational age 33 completed weeks
P07.37Gestational age 34 completed weeks
P07.38Gestational age 35 completed weeks
P07.39Gestational age 36 completed weeks
P04.9Newborn (suspected to be) affected by maternal noxious substance, unspecified
G47.9Sleep disorder, unspecified
R63.6Underweight (Code also BMI)
Emotional/Behavioral Symptoms
F43.20Adjustment disorder, unspecified
F41.9Anxiety disorder, unspecified
F90.0ADHD, inattentive type


ADHD, unspecified type


F90.1ADHD, predominantly hyperactive type
F90.2ADHD, combined type
R41.840Attention and concentration deficit (not ADHD)


Conduct disorder, childhood-onset type

F91.2Conduct disorder, adolescent-onset type
F91.9Conduct disorder, unspecified
F32.9Major depressive disorder, single episode, unspecified
R45.3Demoralization and apathy
F94.2Disinhibited social engagement disorder
F90.9ADHD, unspecified type
F63.81Intermittent explosive disorder
R45.4Irritability and anger
F43.10PTSD, Unspecified
F94.1Reactive attachment disorder of childhood


Other reactions to stress (trauma)

F43.9Reactions to stress, unspecified


Other childhood emotional disorders

F93.9Childhood emotional disorder, unspecified
F94.8Other childhood disorders of social functioning
F94.9Childhood disorder of social functioning,unspec
F98.8Other specified behavioral/emotional disorders w/ onset usually occurring in childhood/adolescence
F98.9 Unspecified behavioral/emotional disorders w/   onset usually occurring in childhood/ adolescence
Development and Cognitive Function


Other symptoms and signs involving the nervous system

​​R29.898Other symptoms and signs involving the musculoskeletal system
F84.0Autistic Disorder  
R48.9Symbolic dysfunctions, unspecified   (includes language delay, learning disabilities)
R41.844Frontal lobe and executive function deficit

Lack of expected normal physiological development in childhood, unspecified


Mild intellectual disabilities

F71Moderate intellectual disabilities
F72Severe intellectual disabilities
F73Profound intellectual disabilities
F78Other intellectual disabilities
F79Unspecified intellectual disabilities
R41.89Other symptoms and signs involving cognitive functions and awareness
F80.89Social Pragmatic Communication Disorder
G93.40Encephalopathy unspecified


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