Billing and Coding for Developmental and Behavioral Problems in Outpatient Primary Care


Billing and Coding for Developmental and Behavioral Problems in Outpatient Primary Care

Lynn Mowbray Wegner, MD, FAAP


NOTE: All testing procedure codes discussed in this chapter will have different Current Procedural Terminology (CPT®) numbers at the time of this book’s publication. The CPT numbers used are correct for CPT 2017.

Evolving and increasing interest by parents and professionals in areas of children’s development and behavioral regulation has resulted in more medical care for children in these areas. Parents and professionals want early identification and ongoing supportive management to ensure optimal cognitive and behavioral development and social adaptation. Getting paid for this care can be problematic, as payers often view visits focusing on preventing problems and ongoing non–face-to-face services as difficult to manage from a cost-containment perspective. Published resources are available to inform medical providers and help them better understand the codes describing services and conditions.1,2

International Classification of Diseases

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)3 is used to classify diseases and operations and is universally used for claims submission. The World Health Organization published the 10th edition in 1993, but it was not adopted by the United States for general use until 2015. The ICD-10 diagnostic codes are meant to completely and accurately describe the patient’s clinical picture. These codes describe why the service was performed. Payers often use these codes as part of risk management (eg, to determine preexisting conditions and refuse payment for diagnoses). The reader is referred to online and printed published editions of ICD-10-CM for comprehensive review of these codes.46

Many of the diagnostic codes in ICD-10-CM Chapter 5, “Mental, Behavioral and Neurodevelopmental Disorders (F01–F99),” are also described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),7 and the “mental health” codes are often referred to during discussions of parity. Just as payers may choose not to pay for some CPT services (such as non–face-to-face care services, eg, telephone calls, e-mail messages, and extended reports), payers also may exclude (in their contracts) care for certain ICD-10 diagnostic codes, either individually or by groups, unless the medical provider is a designated “mental health provider.”

Pediatric health care professionals providing a significant amount of developmental and behavioral care may overcome this obstacle by being paneled as a mental health provider by payers. However, some insurers continue to “carve out” mental health care panels, and there may be future changes in health care administration that might create new bureaucratic quagmires for mental health providers to handle.

Developmental and behavioral conditions often require several medical encounters before a diagnosis can be confirmed. ICD-10-CM has 2 chapters of “descriptive rather than diagnostic” codes; these are Chapter 18, “Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00–R99),” and Chapter 21, “Factors Influencing Health Status and Contact With Health Services (Z00–Z99).” The decision to pay for these codes is decided by each insurer, and while some may allow these codes to be used as the primary diagnosis, other payers will not allow them to be placed on the first line. Other payers may allow the R and Z codes to be the primary diagnosis but only for a specified number of visits. In any case, supportive documentation in the record must be provided.

Current Procedural Terminology (CPT®): Background

As another part of effective and efficient practice planning, it is important to understand how services for developmental/behavioral conditions are described in CPT 2017.2 These procedure codes are Level I codes of the broader-based Healthcare Common Procedure Coding System (HCPCS).8 Level II HCPCS codes, developed by the Centers for Medicare & Medicaid Services (CMS), are 5-digit alphanumeric codes with a letter as the first character and are used to report services and supplies not identified in CPT. CPT allows providers to concisely describe services provided at a patient encounter. If the provider understands the CPT system and stays current to additions and changes to CPT, it is possible to accurately “capture” most, if not all, of the work done. It must be remembered that payers are free to set their individual payment policies. Even when there are published relative value units (RVUs) for a procedure code, payers may refuse to pay for the services.

CMS has a process to assign values (RVUs) to medical service codes. The assumption is that service value is quantifiable, and each service has a relative value based on the resource costs needed to provide each service. Each code value comprises 3 elements: physician work, practice expense (direct and indirect costs), and medical liability expense. These 3 factors (each assigned an individual RVU or part thereof) are summed to get the total RVU. This total RVU is multiplied by a Medicare conversion factor ($ per RVU) and a geographic conversion factor (reflecting that expenses vary from community to community) to give the Medicare payment for that service. Medicare conversion factors are updated every 6 months (January 1 and July 1: 1/1–6/30; 7/1–12/31).

RVUs (either work RVUs or total RVUs) are increasingly being used by group practices and larger institutions to establish benchmarks for physician work and to determine individual salaries. RVUs are used in managed care contracts to determine the costs involved in providing the services. CPT® codes assigned to procedures often have higher RVUs per time unit than codes describing cognitive services.9 This is a particularly relevant concern for pediatric health care professionals offering developmental-behavioral services, as most of this work does not involve procedures; such health care professionals may not be able to generate the same number of RVUs on a given day when compared with a provider who engages in more procedures. Developmental-behavioral specialists and generalists providing developmental and behavioral care can influence charges by advocating for more realistic RVU benchmarks by their administrators. Advocating stronger payment for cognitive services with payers during contract renewal discussions also can help level the playing field.

CPT for Developmental-Behavioral Services

Outpatient face-to-face codes pertinent to developmental-behavioral services describe new, established, consultation, and preventive evaluation and management (E/M) services. Appropriate inpatient hospital CPT codes are also used to describe inpatient services for developmental and behavioral conditions. Codes for developmental screening and objective developmental testing are also available. If a service was modified in some manner, modifiers may be appended to the basic service code to inform the payers that outpatient and/or inpatient services were modified, which may result in a change in charge or payment. Non–face-to-face services are also used when providing developmental and behavioral health care: Codes are available for those services as well as for telephone care, online medical evaluation, care plan oversight, extensive reports, and team conferences.

The current payment system may be used more effectively if providers understand “the system” and appropriately create clinical services in synchrony with the current reimbursement system. This does not mean abandoning quality care, but it does mean understanding efficient care. The following code descriptions are provided to improve code awareness and to link codes to efficient service delivery.

Outpatient Evaluation and Management (E/M) Codes

Outpatient developmental and behavioral care is provided using E/M services. These services include preventive health care (99381–99384; 99391–99394), new (99201–99205) and established (99211–99215) patient office visits, and consultation (99241–99245) services on request of another appropriate professional. A patient is considered new if the provider or any other provider from the same specialty in the same medical group practice either has never provided care or has not seen the patient in the past 3 years in any clinical setting. All E/M services, with the exception of preventive visits, may be coded on the basis of either the complexity of the visit or on the amount of time required for counseling and case management on the date of service. Nonpreventive E/M visit components are defined by 4 levels of service: problem focused, expanded problem focused, detailed problem focused, and comprehensive. Complexity entails consideration of 3 key components: history, physical examination, and the complexity of the medical decision-making required by the provider. Tables 27.1, 27.2, and 27.3 illustrate the 5 levels for consultation and for new and established patient visits.


a Documentation of all components (history, examination, and medical decision-making) is required for all levels of care.


a Documentation of all components (history, examination, and medical decision-making) is required for all levels of care.


Note that the sole difference between the detailed problem-focused and comprehensive levels is the difficulty of medical decision-making. Determining the level of medical decision-making takes into consideration: (1) the number of possible diagnoses and/ or potential treatments; (2) the amount and/or complexity of ancillary information (medical records, diagnostic tests, other information); and (3) the risk of complications, morbidity, and/or mortality associated with the patient’s presenting problem.

The medical record documentation should always support both the ICD-10 and CPT® codes selected. If the provider spends at least half of the visit in counseling or care coordination, then time may be used to determine the CPT code. A statement such as, “The visit took XXX minutes, and more than 50% of time was spent in counseling (and/ or coordination of care),” should be included in the note. The clinician should code the diagnosis to the highest level of diagnostic certainty (the words in the descriptor) and complexity (the numbers in the ICD-10 codes). The first diagnosis listed on the billing sheet should be the condition being actively managed on that date of service. A chronic condition, such as attention-deficit/hyperactivity disorder or depression, managed on an ongoing basis, may be coded and reported as many times as applicable to the patient’s treatment.

There is no provision for “rule out” in ICD-10, but as noted earlier, there is a chapter of codes (Chapter 18, “Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified [R00–R99]”) which may be used if a more definite diagnosis is not possible. Similarly, in ICD-10 Chapter 21, “Factors Influencing Health Status and Contact With Health Services (Z00–Z99),” the factors listed in the Z03 and Z04 ranges can be listed as a first-listed diagnosis only.

While these R and Z codes can be properly used, payers may not choose to pay if these codes (other than Z03 and Z04) are listed first. Remember, payment is always dependent on each payer’s decision.

Preventive Service E/M Codes and Developmental-Behavioral Care10

Health supervision (well-child checkups) and preventive medicine visits are properly described by the preventive medicine services codes (Table 27.4). These codes, like the other E/M codes, are subcategorized as new patient or established patient. Codes in these series are selected based on the age of the patient and not on the basis of time spent on the date of service.

If the pediatric health care professional wants to efficiently cover developmental and behavioral concerns in the typically busy primary care setting, developmental screening instruments and behavioral rating scales can be key procedures. These procedures may properly accompany the preventive service and be described to the payer by appending an appropriate modifier to either the preventive service code, the procedure code, or, in some circumstances, both.

Remember, too, there are preventive medicine visits when a separate medical service is provided, such as when a psychotropic medication refill is needed. These unique services may properly be coded separately provided the medical record shows the documentation of the required elements for the second E/M service.

Table 27.4. Preventive Services for New and Established Patients (99381-99384; 99391-99394)



New Patient


Initial comprehensive preventive medicine evaluation and management; infant (<1 y of age)


early childhood (age 1-4 y)


late childhood (age 5-11 y)


adolescent (age 12-17 y)

Established Patient


Periodic comprehensive preventive medicine evaluation and management; infant (<1 y of age)


early childhood (age 1-4 y)


late childhood (age 5-11 y)


adolescent (age 12-17 y)


Modifiers are 2-digit suffixes appended to the end of a CPT® code to tell the payer that “this visit was different.” The service may have been altered by a specific situation described by the modifier. Some modifiers may be used only with E/M codes, and others may only accompany procedures. Modifier use is extremely important, as modifiers enable the payer software to permit these special circumstances. When modifiers are used, however, the provider must take care to clearly document the circumstances supporting their use. Despite correct modifier use and supportive documentation in the medical record, not all payers recognize all modifiers. Listing modifiers on the billing sheet/electronic health record billing section will encourage their use!

The following modifiers may correctly be appended to E/M codes:

25—Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day as the Procedure or Other Service: This modifier tells the payer the documentation requirements were met for a separate E/M service or procedure on that date. For example, at a preventive care visit, the discussion of current concerns, medication side effects, efficacy, etc, would contribute to the level of the separate E/M service selected. Modifier 25 would be properly appended to the E/M code to address the change in medication and not the preventive medical care visit. The medical record should have 2 separate sections documenting the 2 separate services.

Another example of correct modifier 25 use would be the situation when the parent completes a developmental screening instrument as part of a preventive medical care visit. In that situation, the procedure is described by code 96110 (developmental screening), modifier 25 would be properly appended to the selected 993XX code, and 96110 also would be included as a separate service charge. Again, there must be separate sections in the medical record documenting the 2 provided services.

32—Mandated Services: This modifier is used when a third party requires the service being provided. For example, if a second opinion of a mental health or behavioral diagnosis is required before a child may receive treatment, modifier 32 would be appended to the E/M code describing the visit providing that evaluation service.

Modifiers used with procedures and not E/M codes include

52—Reduced Services: This is used when a procedure is started but then prematurely stopped at the physician’s discretion. This might occur during developmental testing if the child became oppositional and refused to respond to the testing. In that case, 52 would be appended to 96111 (developmental testing, extended) to describe the premature termination of the testing session. The diagnosis code used at this visit should explain why the procedure was reduced. The physician is not required to reduce his or her charges for the reduced service, as the payer will make that decision.

53—Discontinued Service: This modifier might properly be appended to psychological and/or developmental testing codes if the child refused to participate in any of the testing. Why would one go to the trouble of documenting this for the payer? Using this modifier confirms the testing was needed, the test was selected, and time was taken to begin the testing. This may further support the selected level of complexity for medical decision-making. The medical records should, of course, provide documentation.

59—Distinct Procedural Service: This modifier is used when procedures not usually reported together do occur appropriately on the same date of service. It indicates the procedure was distinct from the other procedures performed on that same date of service. Coders refer to this modifier as the “modifier of last resort,” and the physician should be satisfied that no other modifier would be more appropriate. Clear documentation is required to support payment of both procedures. An example of the use of modifier 59 would be a second office visit for developmental testing (96111) during which the parents also returned behavioral/emotional rating scales completed by the patient’s child care provider for scoring and interpretation (96127). Modifier 59 would be appended to the second procedure marked on the billing sheet.

76—Multiple Procedures: Repeat procedures or services performed by the same physician on the same date of service. This code is used when the physician repeats a procedure on the same date. This modifier is appended to the second unit of the procedure to tell the payer more than one of that same procedure was performed. For instance, using 96110 (developmental screening) as an example, if a Pediatric Evaluation of Developmental Status (PEDS)11 or an Ages and Stages Questionnaire12 was completed, scored, and interpreted for a child’s mother (custodial parent), father (has weekly visitation), and daily babysitter, then the 3 forms could be described as

96110 (modifier not put on the first unit)

96110 76

96110 76

Alternatively, as some payers do not want the modifier because they prefer units, the same example would be put on the billing sheet as

(3) 96110

Always follow the payer guidelines!

Psychotherapy Services With E/M

Psychiatrists needed a set of procedure codes to describe medical encounters when both psychotherapy and medication management occurred during a single visit. Table 27.5 lists these services (90833, 90836, and 90838), published by CMS in 2013. These codes describe psychotherapy delivered with the medication E/M. While CMS understood that medication decisions occur while providing therapy, CPT® requires clear documentation of the therapy, the time devoted to therapy, and the key components of the selected E/M service. While any physician qualified to offer psychotherapy may use these codes, payers who “carve out” psychiatric services may require physicians coding psychotherapy to join their mental health panel.


Behavioral Health Integration

The rising demand for improved access to medical care for mental and behavioral conditions is resulting in more models of collaboration between the patient’s primary pediatric health care professional and mental health professionals. In 2017, CMS published codes for 4 services describing behavioral health integration, 3 of which describe services involving the primary qualified health care provider (MD/DO, physician assistant, nurse practitioner), a behavioral care manager, and the psychiatric consultant. Services include enhancing patient engagement, tracking response to interventions, and improved and documented communication with the patient, family members, and other professionals. In 2017, these are listed as G codes—payable by the government for Medicare services; however, it is anticipated these services, or other iterations of them, will eventually become Category I CPT codes.

Developmental and Behavioral Procedures: Screening and Objective Testing

Few procedure codes apply to physician provision of developmental-behavioral services, but those published and valued codes should not be ignored! These procedures include looking for possible areas of concern (screening) (see Chapter 9, Developmental and Behavioral Surveillance and Screening Within the Medical Home), as well as formally assessing performance in one or more areas of development (developmental testing, neurobehavioral status examination, and computerized neuropsychological testing; see Box 27.1).

Box 27.1. Standardized Test Examples for 96111, 96116, 9612511,1327


96111: Developmental Testing; Extended

Beery-Buktenica Test of Visual-Motor Integration (VMI)

Peabody Developmental Motor Scales (PDMS)

Bruininks-Oseretsky Test of Motor Proficiency (BOT)

Clinical Evaluation of Language Fundamentals (CELF)

Bayley Scales of Infant and Toddler Development

Capute Scales (Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale; CAT/CLAMS)

Mullen Scales of Early Learning (MSEL)

Parents’ Evaluation28,29 of Developmental Status: Developmental Milestones, assessment level (PEDS:DM, assessment level)

Battelle Developmental Inventory (BDI)

Brigance Inventory of Early Development

Peabody Picture Vocabulary Test (PPVT)

Kaufman Brief Intelligence Test (KBIT)

Wide Range Achievement Test (WRAT)

96116: Neurobehavioral Status Examination

Woodcock-Johnson Tests of Cognitive Abilities (WJ-TCA)

Autism Diagnostic Observation Scale (ADOS)

Psychoeducational Profile (PEP)

96125: Standardized Cognitive Performance Testing

Comprehensive Test of Nonverbal Intelligence (C-TONI)

Tests of Nonverbal Intelligence (TONI)

Woodcock-Johnson Tests of Cognitive Abilities: Thinking Ability Index

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Oct 22, 2019 | Posted by in PEDIATRICS | Comments Off on Billing and Coding for Developmental and Behavioral Problems in Outpatient Primary Care
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