Diagnosis Coding for Pediatric Visits
For routine pediatric preventive care visits, use CPT codes 99381-99394 (EPSDT) for the visit type, and pair these with appropriate ICD-10-CM diagnosis codes that reflect the specific reason for the encounter, such as Z00.121 (routine child health examination with abnormal findings) or Z00.129 (routine child health examination without abnormal findings). 1
Primary Visit Coding Structure
Preventive Care Visits
- Well-child visits should be coded using CPT codes 99381-99394, which represent comprehensive preventive medicine services for established and new patients at different age ranges 1
- The primary diagnosis code should reflect the preventive nature of the visit using Z codes (Z00.121 for abnormal findings, Z00.129 for normal findings) 1
Problem-Focused Visits
- New patient evaluations use CPT codes 99201-99205, with 99204 for detailed/moderately complex evaluations taking at least 45 minutes, and 99205 for comprehensive/highly complex evaluations taking 60 minutes 1
- Established patient visits use CPT codes 99210-99215, with 99214 for detailed/moderately complex visits taking at least 25 minutes, and 99215 for comprehensive/highly complex visits taking 40 minutes 1
- The primary diagnosis code should reflect the specific condition being evaluated or managed 2
Developmental Screening and Surveillance
Screening Codes
- Developmental screening (CPT 96110) can be reported in addition to evaluation and management services on the same date and does not require physician work, as clinical staff can score results 1
- Extended developmental testing (CPT 96111) is used for testing typically provided by the medical provider, often up to 1 hour, including evaluation interpretation and report 1
- Standardized developmental screening should be performed at 9-, 18-, and 30-month visits (or 24 months if 30-month visit is not feasible) 3
Diagnosis Codes for Developmental Concerns
- When developmental delays are identified, use specific ICD-10-CM codes that reflect the type of delay (motor, speech, cognitive) 2
- Children identified with developmental disorders should be classified as children with special health care needs, initiating chronic condition management 1
Special Populations and Conditions
Children with Special Health Care Needs
- Use higher-level outpatient codes (99214-99215) as these children require expanded time and higher levels of medical decision-making 1
- These codes may be reported using time alone as the determining factor if more than half of the reported time is spent in counseling 1
- The pediatric complex chronic condition (CCC) system version 3 should be used to identify and code complex chronic conditions in children 4
Prolonged Services
- When visits require considerably more time than typical for the base code, prolonged physician service codes (99354 for first 30-74 minutes face-to-face, 99355 for each additional 30 minutes) may be reported in addition to outpatient office or consultation codes 1
Common Pitfalls and Best Practices
Accurate Coding Requirements
- Providers are ultimately responsible for medical record documentation and diagnosis coding, requiring basic understanding of ICD-10-CM structure, conventions, and rules 2
- Diagnosis codes must communicate the specific reason for health care encounters and conditions treated 2
Avoiding Alternate Coding Issues
- While alternate coding practices have been reported in pediatric behavioral and mental health settings, proper diagnostic coding should reflect the actual clinical condition being evaluated or managed 5
- Financial pressures should not drive inappropriate code selection, as this may affect administrative data, patient care, and health care economics 5