Is the pediatric behavioral health evaluation and management visit template accurate and comprehensive for non-Medicare patients, including correct billing instructions for telehealth services using 980xx codes?

Pediatric Behavioral Health Template Critique

Overall Assessment

Your template structure is clinically comprehensive and appropriate for pediatric behavioral health evaluation and management visits, but your billing instructions contain a critical error regarding telehealth coding that requires immediate correction.

Critical Billing Error: Telehealth CPT Codes

The use of 980xx codes for telehealth services is fundamentally incorrect and will result in claim denials. 1

Correct Telehealth Billing Approach

• Use standard E/M codes (99202-99215 for office visits, 99381-99397 for preventive services) with telehealth-specific modifiers or place of service codes, not separate 980xx codes 1
• The 980xx code range does not exist in standard CPT coding nomenclature for evaluation and management services 1
• Following COVID-19 regulatory changes, most commercial payers accept standard E/M codes with modifier 95 (synchronous telemedicine) or place of service code 02 (telehealth) 1
• Your insurer preference for "980xx codes" likely represents a miscommunication or outdated internal documentation that needs clarification with your payer contracts 1

Pediatric-Specific Telehealth Considerations

• Behavioral and mental health concerns are particularly amenable to virtual care and represent one of the most appropriate use cases for pediatric telehealth 1
• Telehealth for behavioral health visits increased dramatically during the pandemic, with practices successfully adopting it for ADHD management, depression screening, and behavioral problems 1
• Privacy challenges during adolescent behavioral telehealth require specific protocols: asking adolescents to move to private spaces, having family members leave the room, or using headphones with yes/no format questions 1

Template Content Strengths

Clinically Appropriate Sections

Your template includes all essential components for comprehensive behavioral health documentation 2, 3, 4

• Clinical Concerns, Reason for Consultation, and Information Sources provide necessary context for medical decision-making complexity 2, 3
• Psychometric Assessment Results section is excellent and aligns with evidence-based screening practices using validated instruments 2
• Mental Status Examination is essential for behavioral health visits and supports appropriate E/M level selection 2, 3
• Risk assessment is critical for pediatric behavioral health and directly impacts medical decision-making complexity 3
• Medication review and Notes on Current Medications are particularly important given polypharmacy concerns in behavioral health 2, 3

Documentation Supporting Billing

Your template structure supports appropriate E/M code selection through comprehensive documentation 1

• The inclusion of MDM (Medical Decision Making) calculation logic is essential for 2021+ E/M coding guidelines 1
• Separate sections for orders, labs/diagnostics/imaging/referrals, and prescriptions directly support MDM complexity determination 1
• Visit diagnoses section allows for appropriate ICD-10 coding to support medical necessity 1

Template Content Recommendations

Add Privacy and Consent Documentation

Include specific documentation fields for telehealth-specific consent and privacy measures 1

• Document location of patient during telehealth visit (home, school, other) 1
• For adolescents, document privacy measures taken (private room, headphones, family members excluded) 1
• Document any barriers to confidential communication identified during visit 1
• Your AI scribe disclosure is appropriate but should also document patient/caregiver verbal consent 1

Enhance Home Environment Assessment

Telehealth behavioral health visits provide unique opportunities for psychosocial assessment 1

• Add template field for visual assessment of home environment when applicable 1
• Include documentation of psychosocial concerns identified (food insecurity, safety concerns, family dynamics) 1
• This documentation supports higher complexity MDM and may justify additional social work referrals 1

Specify Psychometric Instruments Used

Your template should prompt for specific validated screening tools 2

• Document which instruments were administered (PSC-17, PHQ-9, SCARED, or others) 2
• Include raw scores and clinical interpretation for each instrument 2
• This specificity supports medical necessity and appropriate E/M level selection 2

Billing Section Corrections Needed

Remove or Correct "TELEMEDICINE E/M" Section

Replace your current telehealth billing guidance with accurate coding instructions 1

• For synchronous video visits: Use standard E/M codes (99202-99215 for problem-focused, 99381-99397 for preventive) with modifier 95 or place of service 02 1
• For telephone-only visits: Use codes 99441-99443 (physician) or 98966-98968 (qualified healthcare professional) based on time spent 1
• Document total time spent and whether visit was audio-only or audio-video 1
• Verify your specific commercial payer contracts for any unique telehealth billing requirements 1

Clarify "TELEPHONE E/M" Section

Telephone E/M codes are distinct from video telehealth and have specific requirements 1

• Telephone codes (99441-99443) are time-based: 5-10 minutes (99441), 11-20 minutes (99442), 21-30 minutes (99443) 1
• These codes cannot be billed if the call results in a visit within 24 hours or is related to a visit within the previous 7 days 1
• Many payers have different reimbursement rates for telephone versus video visits 1

Developmental Testing Section

Ensure your developmental testing codes are appropriate for behavioral health context 2, 5

• Developmental screening (96110) can be billed separately from E/M with modifier 25 2, 5
• Standardized behavioral health screening instruments may be separately billable depending on payer 2
• Document time spent on screening administration and interpretation 2

Common Pitfalls to Avoid

Billing and Documentation Errors

Insufficient documentation of time for time-based codes will result in downcoding or denials 1

• For prolonged services codes (99354-99355), document exact start and stop times 1
• For telephone codes, document total time of medical discussion (not just call duration) 1
• Ensure MDM elements (diagnoses, data reviewed, risk) are explicitly documented to support code selection 1

Telehealth-Specific Pitfalls

Technology failures and privacy breaches are common telehealth risks requiring documentation 1

• Document any technical difficulties encountered and how they were resolved 1
• If visit quality was compromised by technology, document impact on medical decision-making 1
• Ensure HIPAA-compliant platforms are used and documented 1
• Training on telehealth workflows, documentation, and billing should be provided to all staff using this template 1

Modifier Usage

Failure to use appropriate modifiers will result in claim denials 1

• Modifier 25 is required when billing E/M and procedure codes (like screening) on same day 1
• Modifier 95 or place of service 02 is required for telehealth E/M services with most payers 1
• Do not use modifier 25 with preventive medicine codes unless truly billing separate problem-focused E/M 6

Medicare Exclusion Clarification

Your statement about not seeing Medicare patients is appropriate but requires nuance 6, 7

• While pediatric practices rarely see traditional Medicare patients, some children qualify for Medicare due to disability or end-stage renal disease 6
• If you do encounter Medicare patients, wellness visit coding differs significantly (G0438/G0439 instead of 99381-99397) 7
• Medicaid (which you likely do see) has specific EPSDT requirements for preventive services with no cost-sharing allowed 6

Final Recommendations

Immediately contact your billing department and commercial payers to clarify correct telehealth coding requirements 1

• Request written documentation of accepted telehealth codes and modifiers from each payer 1
• Update your billing criteria library to reflect standard CPT codes with appropriate modifiers 1
• Provide staff training on corrected billing procedures before template implementation 1
• Consider implementing the STEM (SPROUT Telehealth Evaluation and Measurement) framework to evaluate your telehealth program quality and outcomes 1