What are the recommended billing codes and documentation guidelines for telehealth visits in pediatric behavioral health evaluations?

Billing and Documentation for Pediatric Behavioral Health Telehealth Visits

Direct Answer to Your Template Review

Your template is fundamentally sound for content and structure, but you must use standard CPT codes (99211-99215 for established patients, 90791-90863 for psychiatric services) with Modifier 95 for audio-video telehealth—not "980xx" codes, which do not exist in standard medical billing nomenclature. 1

Critical Billing Code Corrections

The "980xx" Problem

• The codes you reference as "980xx" are not recognized CPT or HCPCS codes for telehealth billing. 1
• For synchronous audio-video telehealth in pediatric behavioral health, you must use standard psychiatric CPT codes (90791,90792,90832-90838,90846-90847,90863) or E/M codes (99211-99215 for established patients, 99201-99205 for new patients) with Modifier 95 appended. 1, 2
• Modifier 95 certifies that services were provided via interactive audio and video telecommunications systems permitting real-time communication. 1, 2

Correct Telehealth Coding Structure

• Audio-video visits: Use appropriate CPT code + Modifier 95 (e.g., 99214-95 or 90834-95). 1, 3
• Audio-only visits: Use telephone E/M codes (99441-99443 for 5-10,11-20, or 21-30 minutes respectively) which are time-based only. 1, 4
• Place of Service code: Must be appropriate for telehealth (typically POS 02 for telehealth provided in patient's home). 1

Template Content Assessment

Strengths of Your Template

• Comprehensive clinical documentation: Your sections for MSE, diagnosis with ICD-10, current medications, risk assessment, and medication management align with standard psychiatric documentation requirements. 1
• Structured billing logic: Including MDM calculation and time-based billing alternatives is appropriate, as you can bill based on either complexity or time, whichever is higher. 1, 5
• Orders extraction: Separating prescriptions, labs, diagnostics, and referrals with ICD-10 linkage supports medical necessity documentation. 6

Required Additions for Telehealth Compliance

You must add these specific documentation elements to meet telehealth billing requirements: 1

• Patient consent to telemedicine (document that informed consent was obtained)
• Method of telemedicine (specify "secure 2-way interactive audio-video" or "audio-only telephone")
• Patient location (city and state where patient is physically located during visit)
• Provider location (city and state where you are physically located)
• All participants present (list anyone else in the room with patient or provider)
• Licensure verification statement (confirm you are licensed in the state where patient is located) 1

Privacy and Technology Documentation

• Your AI scribe disclosure is appropriate and should remain. 1
• Document the specific HIPAA-compliant platform used (e.g., "Zoom for Healthcare," "Doxy.me," institutional EHR video platform). 1
• Note any technical difficulties encountered and how they were resolved. 1

Medication Review Visit Specifics

Appropriate CPT Codes for Medication Management

• For medication review visits in established patients, use 99212-99215 based on complexity or time. 1, 7
• Alternatively, use psychiatric codes: 90863 (pharmacologic management, 15+ minutes) or 90832-90838 (psychotherapy with E/M). 1
• The choice depends on whether psychotherapy is provided alongside medication management. 1

Medical Decision-Making (MDM) Components

Your template should explicitly capture these MDM elements for proper code selection: 1

• Number and complexity of problems addressed (chronic with exacerbation = moderate; chronic with severe exacerbation or new problem with uncertain prognosis = high)
• Amount and complexity of data reviewed (review of prior records, psychometric assessments, external records)
• Risk of complications (prescription drug management = moderate risk minimum; consider higher if multiple medications or high-risk medications)

Psychometric Assessment Billing

• If you administer and interpret standardized developmental testing, bill 96112 (first hour) and 96113 (each additional hour) separately from the E/M visit. 1
• These codes require formal, standardized instruments with scoring and interpretation, not just screening tools. 1
• Document the specific test administered (e.g., WISC-V, Conners, CBCL) and time spent. 1

State Licensure and Geographic Restrictions

Critical pitfall: You must be licensed in the state where the patient is physically located during the telehealth visit. 1

• During COVID-19 emergency declarations, many states waived this requirement, but most have reinstated it. 1
• Verify patient location at the start of every telehealth visit and document it. 1
• If patient is in a state where you lack licensure, you cannot legally provide care via telehealth. 1

Reimbursement Considerations

Current Payer Landscape

• Medicare and most commercial payers reimburse audio-video telehealth at parity with in-person visits when billed correctly with Modifier 95. 1
• Audio-only visits have variable reimbursement and are typically paid at lower rates using telephone E/M codes (99441-99443). 1
• Medicaid coverage varies by state but all 50 states now provide some telehealth reimbursement. 1

Documentation to Support Medical Necessity

• Justify why telehealth is appropriate for this specific visit (e.g., "Patient lives 90 miles from clinic," "Patient has transportation barriers," "Follow-up medication management appropriate for virtual care"). 1
• Note any limitations of virtual examination and how you addressed them. 1
• Document that the quality of care was not compromised by the virtual modality. 1

Behavioral Health-Specific Considerations

Privacy for Adolescents

• For adolescent patients, document how you ensured privacy (e.g., "Patient confirmed alone in room with door closed," "Family members asked to leave," "Patient using headphones"). 1
• This is particularly critical for SBIRT (screening, brief intervention, referral to treatment) and sensitive mental health topics. 1

Home Environment Assessment

• Telehealth provides unique opportunity to observe home environment—document relevant observations about safety, family dynamics, or psychosocial stressors visible during the visit. 1, 8
• This can support higher complexity coding when environmental factors significantly impact treatment planning. 8

Common Billing Pitfalls to Avoid

1. Using non-existent "980xx" codes instead of standard CPT codes with Modifier 95 1
2. Forgetting to append Modifier 95 to audio-video visits (claim will be denied or paid as audio-only) 2, 3
3. Billing audio-only visits with E/M codes instead of telephone codes 99441-99443 1, 4
4. Inadequate documentation of telehealth-specific elements (patient location, consent, platform used) 1
5. Providing care to patients in states where you lack licensure 1
6. Billing for time without documenting total time spent (must document start and stop times or total minutes) 1

Final Template Recommendations

Modify your billing section to read:

BILLING SECTION

• Recommended CPT Code: [99212-99215 or 90832-90838 or 90863]
• Modifier: 95 (for audio-video) or use 99441-99443 (for audio-only)
• Place of Service: 02 (Telehealth)
• Basis: [MDM Level: Straightforward/Low/Moderate/High] OR [Total Time: XX minutes]
• Telehealth Documentation: Interactive audio-video via [platform name], patient located in [city, state], provider located in [city, state], patient consent obtained, [list others present]

This structure ensures compliance with current telehealth billing requirements while supporting appropriate reimbursement for your pediatric behavioral health services. 1, 2, 3