Optimal Clinical Coding for CYSHCN
Overview
International Classification of Diseases (ICD-10) Coding
Q20-28 Congenital malformations of the circulatory system
- Q21 Congenital malformations of cardiac septa
- Q 21.3 Tetralogy of Fallot
H65-H75 Diseases of middle ear and mastoid
- H66 Suppurative and unspecified otitis media
- H66.00 Acute suppurative otitis media without
spontaneous rupture of eardrum
- H66.004 Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
- H66.00 Acute suppurative otitis media without
spontaneous rupture of eardrum
ICD-10 Diagnostic Coding for Unknown Diagnoses
- Fever [R50.9]
- Hemoglobinuria [R82.3]
- Macrocephaly [Q75.3]
- Low-birth weight, 1500-1999 grams [P07.17]
- Routine child health check with abnormal findings [Z00.121]
- Fall from non-moving wheelchair, initial encounter [W05.0XXA]
Current Procedural Terminology (CPT) Coding
Evaluation and Management Services
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Adolescent Confidentiality Related to Billing (
615 KB)
-
Adolescent Health Services (
79 KB)
-
After-hours and Special Services (
84 KB) (urgent and when not regularly scheduled)
-
Coding for Pediatric Preventive Care (AAP) (
2.0 MB)
-
Oral Health (
223 KB)
-
Osteopathic Manipulation (
)
-
Telehealth (
245 KB)
-
Transition to Adult Health Care (
426 KB)
- Various mental health/behavioral issues, including
ADHD (
149 KB) and Anxiety (
148 KB)
Medical Home Services

Care Plan Oversight Services
- The appropriate code is based on total time within a calendar month: 99339 (15-29 minutes) or 99340 (30 minutes or more).
Home Services
- For new patients, 99341-99345, with typical duration from 20 to 75 minutes
- For established patients, 99347-99350, with typical duration from 15 to 60 minutes

Prolonged Services With Direct Patient Contact
- 99354 is used for the first “hour” (30-74 minutes) of prolonged services; this code may be used only once for a given date.
- 99355 is used for each additional 30 minutes beyond the first hour (total of 75-104 minutes, 105-134 minutes, etc.) on a given date.
Prolonged Services Without Direct Patient Contact
- 99358 is used for the first “hour” (30-74 minutes) of prolonged services; this code may be used only once for a given date.
- 99359 is used for each additional 30 minutes beyond the first hour (total of 75-104 minutes, 105-134 minutes, etc.) on a given date.
Medical Team Conferences
- 99366 is used by nonphysician qualified health care professionals for participation in conferences of 30 minutes or more, with patient and/or family present.
- 99367 is used by physicians for participation in conferences of 30 minutes or more, with the patient or family not present. (Physicians should use E/M codes to report time in team conferences with the patient and/or family present.)
- 99368 is used by nonphysician qualified health care professionals for participation in conferences of 30 minutes or more, with patient or family not present.
General Behavioral Health Integration Care Management
Care Management Services
- 99487 is used for establishment/substantial revision of a comprehensive care plan involving moderate-high complexity medical decision-making requiring 60 minutes of clinical staff time in a calendar month
- 99489 is used to report each additional 30 minutes required in a calendar month
- 99490 is used for establishment, implementation, revision, or monitoring of a comprehensive care plan requiring at least 20 minutes of clinical staff time in a calendar month
- 99491 is used for establishment, implementation, revision, or monitoring of a comprehensive care plan requiring at least 30 minutes of physician or other qualified health care professional time in a calendar month
Principal Care Management (PCM) Services
- G2064. CCM for a single high-risk disease (i.e., PCM) at least 30 minutes of physician or other qualified health care professional time per calendar month
- G2065. CCM for a single high-risk disease, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month
Transitional Care Management Services
- 99495 includes communication (direct contact, telephone, electronic) with the patient/caregiver within 2 business days and a face‐to‐face visit within 14 calendar days of discharge and medical decision‐making of at least moderate complexity
- 99496 includes communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days, a face‐to‐face visit within 7 calendar days of discharge, and medical decision‐making of high complexity
Telephone Services
- 99441 involves 5-10 minutes of medical discussion
- 99442 involves 11-20 minutes of medical discussion
- 99443 involves 21-30 minutes of medical discussion
Online Medical Evaluation
- 99421. Online digital E/M service, for an established patient, 5-10 minutes cumulative time over up to seven days
- 99422. Online digital E/M service, for an established patient, 11-20 minutes cumulative time over up to seven days
- 99423. Online digital E/M service, for an established patient, 21 or more minutes cumulative time over up to seven days
Interprofessional Telephone/Internet/Electronic Health Record Consultations
- 99446 involves 5-10 minutes of medical consultative discussion and review
- 99447 involves 11-20 minutes of medical consultative discussion and review
- 99448 involves 21-30 minutes of medical consultative discussion and review
- 99449 involves 31 minutes or more of medical consultative discussion and review
Education and Training for Patient Self-Management
- 98960 – an individual patient
- 98961 – 2-4 patients
- 98962 – 5-8 patients
Resources
Information & Support
For Professionals
Medical Home Resources (AAP)
An in-depth look at the medical home model and how to implement it. Includes information about quality improvement, maintenance
of certification activities to improve your medical home, and financing and payment resources; American Academy of Pediatrics.
Coding Resources (AAP)
Books, quick references, and how-to guides for CPT and ICD-10 coding specific to pediatrics; available for purchase from the
American Academy of Pediatrics.
Coding for Transition-Related Services ( 509 KB)
Detailed overview of CPT coding options for the provision of transition-related services; from Got Transition and the American
Academy of Pediatrics.
Coding Guidelines (AAP)
Explains the elements needed for coding evaluation and management services, such as the level of visit and decision-making,
complexity of exam, risk of complications, and data to be reviewed; American Academy of Pediatrics.
CPT (Current Procedural Terminology)
Link to the American Medical Association Store where the current version of the CPT can be purchased in hardcopy.
ICD10Data.com
Free, user-friendly reference website that contains all of the official American ICD-10-CM (diagnosis) and ICD-10-PCS (procedure)
medical billing codes.
Physician Fee Schedule Look-Up Tool (CMS)
Offers information on each CPT (aka Healthcare Common Procedure Coding System, HCPCS) code, including assigned relative value
units (RVUs), payment amounts (both national and by specific localities) and more; from the Centers for Medicare and Medicaid
Services (CMS)
Prolonged Services Codes: Criteria for Use (AAP)
How to code for prolonged non-direct and direct services provided by physicians and other qualified health care professionals;
American Academy of Pediatrics.