Coding for Developmental & Mental Health Screening

ICD-10 and CPT Coding for billing and tracking pediatric developmental and mental health screening

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, and 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 direct their providers to bill differently from the American Medical Association's CPT guidelines. Detailed coding and billing, even if not paid by Medicaid or the insurer, are useful to track work value (RVU).

Other Names & Coding

Billing and coding for developmental and/or autism screening
Billing and coding for behavioral health (ADHD, anxiety, depression) screening
Billing and coding for caregiver depression screening
Billing and coding for substance abuse screening

Key Points

Importance of coding
Accurate, detailed coding, even for items not currently reimbursable, helps reflect the actual clinical effort and identifies codes that may need to be reimbursable in the future to optimize care for children with special health care needs.

ICD-10 vs. CPT Codes

International Classification of Diseases, Tenth Revision (ICD-10) and Current Procedural Terminology (CPT) codes are ways to briefly communicate a patient interaction for disease tracking and billing. ICD-10 and CPT codes are different in the type of information they convey.

ICD-10 Codes

ICD codes refer to the specific condition or situation being addressed. These codes are a standard diagnostic language to communicate what you address during a visit. They are 3-7 characters long and allow for specificity.
Structure of ICD-10 Code:

Anatomy of an ICD-10 Code

CPT Codes

CPT codes describe the care that was provided. This can include screening, procedures, labs, and imaging. These codes are a standard procedural language to communicate what was done during a visit.

  • Each CPT code has an RVU (relative value unit) used by payers to determine payment
  • Medicare uses a conversion factor for each RVU. In 2022, for example, 1 RVU was equivalent to $34.6062)
  • 99213 – 5:
    • 99213 = 2.66 RVUs
    • 99214 = 3.75 RVUs
    • 99215 = 5.29 RVUs
  • Miscoded encounters can lead to significantly decreased compensation for the work provided.

ICD-10-CM Codes for Screening

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
You do not need to add Z13.3* as a secondary code to a well-child check when performing routine depression and substance use screens. If a Z00.1* well-child exam and a Z13.3* behavioral health exam are both unique reasons for the visit, list Z00.1* first, as the primary code, and Z13.3* as a secondary code.

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
There is no need to add Z13.4* as a secondary code to a well-child check when performing routine developmental and autism screening. If a Z00.1* well-child exam and a Z13.4* developmental screening exam are both unique reasons for the visit, list Z00.1* first as the primary code and then list Z13.4* as a secondary code. For example, both codes could be used during a well-child check if additional screening for ADHD or anxiety is administered.

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 for Screening

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 they 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.

CPT Code Examples of Screens
96110 Developmental screening (e.g., developmental milestone survey, speech and language delay screen, autism screen) M-CHAT, ASQ-3rd Edition, PEDS, SWYC
96127 Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale) ASQ-SE, SCARED, Vanderbilt, PSC, PHQ-2, PHQ-9 or adolescent version, Connors
96160 Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) CRAFFT, AUDIT, BSTAD, S2BI, DAST-20
96161* Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient Edinburgh Postnatal Depression Scale (English), PHQ-2, PHQ-9 administered to caregiver during a baby’s visit

Payers vary in their requirements and reimbursements for screening instruments.

Modifiers 25 and 59

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.

Coding Examples

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

During an 18-month, well-child visit, the parent completes an autism screen and a developmental screen. The clinician reviews the results of both screens with the family and documents them appropriately in the visit note. The child also has an ear infection requiring treatment.
CPT Codes Associated ICD-10-CM Codes
99392*25 Early childhood preventive medicine services Z00.121 Well-child check with abnormal findings (primary diagnosis)
96110 x 2 developmental screens (reimbursement varies) Z00.121
99213 distinct E/M service H66* suppurative otitis media

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

During a well-child visit for a healthy 4-month-old, the mother completed a SWYC developmental screen for the infant, which is normal. She also completed an Edinburgh maternal depression screen, which was abnormal. The provider spends an additional 10 minutes talking with the mom and contacting the social worker.
CPT Codes Associated ICD-10-CM Codes^
99391*25 Infant preventive medicine services SWYC Z00.121 Well-child check with abnormal findings (primary diagnosis)
96110 Developmental screen – Child development screening Z00.121
96161 Caregiver assessment (Edinburgh) Mother depression screening Z00.121
^Do not report Z13.3* (maternal depression codes) as diagnoses in the baby’s chart; they belong in the maternal record.
The provider is advised not to add time-based billing for the parent counseling. Refer the parent to her own provider for additional care.

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

During a well-child visit for an established 17-year-old, the patient completes a PHQ-9 and a CRAFFT 2.1, both of which are normal. The adolescent reports feeling anxious in crowds and talking in front of the class at school. In addition to the routine depression and risky substance use screeners completed at check-in, the patient also completes a SCARED Version for Child (anxiety screen), which is abnormal. The provider briefly discusses the results with the patient and then recommends a follow-up visit focused on anxiety.
CPT Codes Associated ICD-10-CM Codes
99394*25 Adolescent preventive medicine services Z00.121 Well-child check with abnormal findings (primary diagnosis)
96127x2 Brief emotional/behavioral assessment (PHQ-9 Depression) and (SCARED anxiety) Z00.121
Z13.39 Encounter for screening examination for other mental health and behavioral disorders
96160*59 Patient-focused health risk assessment instrument (CRAFFT Health Hazard/Alcohol use)^ Z00.121
^Note that the likelihood of reimbursement for the 96160 is low because the 96160 can be considered a component of the 96127 code. Ensure that the documentation validates that the 96160 is a separate risk assessment.

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

During a 40-minute visit to follow up with an established patient previously diagnosed with ADHD and anxiety, the clinician discusses the latest results of the Follow-Up Vanderbilt for Teacher, the Follow-Up Vanderbilt for Parent (ADHD monitoring instruments), and the GAD-7 anxiety screen completed by the patient online before the visit. Medication adjustments are made, as well as counseling on relaxation exercises.
CPT Codes Associated ICD-10-CM Codes
99215*25 Time-based E/M (includes face-to-face and non-face-to-face time) F90.2 ADHD combined type (primary diagnosis)
96127 x 3 Brief emotional/behavioral assessment F90.2
F40.10 Social anxiety disorder

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

An established 18-month-old patient presents for an E/M visit for an ear infection requiring treatment. During the visit, the provider realizes that the 18-month-old child missed his last well-child check and administers a developmental screen and an autism screen. The clinician reviews the results with the family.
CPT Codes Associated ICD-10-CM Codes
99213*25 E/M services H66* suppurative otitis media (primary diagnosis)
96110 x2 Developmental screens Z134.42 screening for global developmental delay

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

When you are wrapping up a short visit to assess a rash in a 14-year-old male established patient, his father expresses concerns that he seems depressed. You administer a Patient Health Questionnaire (PHQ-9/A) (adolescent version), which is positive for depression, and a Drug Abuse Screening Test (DAST-10), which is negative for risky substance use. You spend 32 minutes in total reviewing the screens, prescribing an anti-depressant, and general counseling.
CPT Codes Associated ICD-10-CM Codes
99214 Time-based E/M services (includes face-to-face and non-face-to-face time) R21 Rash and other nonspecific skin eruption (primary diagnosis)
Z71.89 Other specified counseling
96127 Brief emotional screener (PHQ-9/A) Z13.30 Encounter for mental health and behavioral screening
F32.9 Major depressive disorder, single episode
96160 Health risk assessment (DAST-10) Z13.30

Example 7. Wart Removal Plus New Behavioral Concerns

During a 7-year-old's new patient visit to your clinic for a wart removal with liquid nitrogen, the family asks how to tell if she might have ADHD. In 10 minutes, you take a short history of their concerns and describe the diagnostic process for ADHD. You provide Vanderbilts (ADHD screeners) for them to complete after the visit and ask them to set up a follow-up visit.
CPT Codes Associated ICD-10-CM Codes
17110 Destruction of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions B07.9 Viral warts, unspecified (primary diagnosis)
99202*25 Time-based E/M, new patient (includes face-to-face and non-face-to-face time) Z73.9 Problem related to life management difficulty, unspecified
^The 25-modifier is only placed on E/M CPT codes (e.g., the 99201). Modifier 25 is not considered valid when appended to surgical codes, medical procedures, diagnostic tests, procedures, etc., so it does not append the 17110 code in this example.
Note that screens were not administered or reviewed during this visit, so you do not include the screening CPT codes.

Example 8. Subsequent Wart Removal Plus Discussion of Screening Results

At the next visit, you spend 32 minutes reviewing the screens and making recommendations for treatment of her newly diagnosed ADHD. You also perform wart removal.
CPT Codes Associated ICD-10-CM Codes
99214*25 Time-based E/M (includes face-to-face and non-face-to-face time) F90.0 ADHD, inattentive type
96127 x2 Brief emotional screeners (both Vanderbilts) F90.0
Z13.39 Encounter for screening examination for other mental health and behavioral disorders
17110 Destruction of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions B07.9 Viral warts, unspecified (primary diagnosis)


Information & Support

For Professionals

Coding Fact Sheets (AAP)
Codes for medical home visits, mental health care, oral health, screening, and more that clinicians can submit to insurance carriers for payment of medical services; American Academy of Pediatrics.

Coding for Pediatric Preventive Care, 2022 (Bright Futures) (PDF Document 2.0 MB)
Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) Level II, and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes most commonly reported by pediatricians in providing preventive care services; American Academy of Pediatrics/Bright Futures.

Pediatric ICD-10-CM 2024, 9th Edition (AAP)
Condenses the vast ICD-10-CM code set into only pediatric-centered guidelines and codes; American Academy of Pediatrics Committee on Coding and Nomenclature (COCN).

Pediatric Coding Basics: An Introduction to Medical Coding (AAP)
available for a cost; AAP Committee on Coding and Nomenclature (COCN)

Pediatric Evaluation and Management Coding Quick Reference Card 2024 (AAP)
All 2024 changes in evaluation and management (E/M) codes - available for purchse only; American Academy of Pediatrics and American Committee on Coding and Nomenclature (COCN).

AAP Coding Hotline and Hassle Factor Form
Online form for help with coding; American Academy of Pediatrics.

Authors & Reviewers

Initial publication: October 2019; last update/revision: February 2024
Current Authors and Reviewers:
Author: Alanna Brickley, MD
Reviewer: Jason Fox, MPA/MHA
Authoring history
2019: first version: Jennifer Goldman, MD, MRP, FAAPA; Jason Fox, MPA/MHAR; Andrea Reeder, MBA, CPCR
AAuthor; CAContributing Author; SASenior Author; RReviewer