Initial assessment usually involves a lot of time determining the

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

Anxiety Coding Fact Sheet for Primary Care Pediatrics

Current Procedural Terminology (CPT

) Codes

Initial assessment usually involves a lot of time determining the differential diagnosis, a diagnostic plan, and potential

treatment options. Therefore, most pediatricians will report either an office/outpatient evaluation and management

(E/M) code using time as the key factor or a consultation code for the initial assessment:

Physician Evaluation & Management Services

99202 Office or other outpatient visit, new patient; straightforward medical decision making (MDM), 15-29 min.

99203 low MDM, 30-44 min.

99204 moderate MDM, 45-59 min.

99205 high MDM, 60-74 min.

A new patient is one who has not received any professional services face-to-face services rendered by physicians and other qualified health care professionals (QHP) who

may report evaluation and management services reported by a specific CPT code(s) from the physician/QHP or another physician/QHP of the exact same specialty and

subspecialty who belongs to the same group practice, within the past three years.

99211 Office or other outpatient visit, established patient; minimal problem, 5 min.

99212 straightforward MDM, 10-19 min.

99213 low MDM, 20-29 min.

99214 moderate MDM, 30-39 min.

99215 high MDM, 40-54 min.

+99417 Prolonged physician services in office or other outpatient setting, with direct patient contact; first hour (use

in conjunction with codes 99205, 99215 only)

• Used only with the highest level E/M services (99205, 99215)

• Time spent does not have to be continuous but must occur on the same day as the face-to-face encounter

• Prolonged service begins at 75 minutes for new patients (99205 and 99417) and 55 minutes for established

patients (99215 and 99417)

• Prolonged time can include non-direct services on the same day as the encounter

Reporting E/M services using “Time” vs MDM

• A physician will report their level of E/M service using time or MDM

• If reporting based on “time” count all time on the encounter date, including pre- and post service time spent on

that patient, even if the patient is not present

• You do not have to meet “time” requirements in the code descriptor to meet a code level if billing based on MDM

Example: A physician sees an established patient in the office to discuss the progress being made on the anti-anxiety

medication and using anxiety support apps. The patient’s chronic medical condition is not stable and is being managed by

medication (moderate level MDM). The total face-to-face time was 35 minutes, with an additional 10 minutes of

documented time after the patient left. The physician would report a 99215 instead of a 99214 because the total time met

the criteria for the 99215 (25 mins) which was higher than the MDM level (moderate) for the 99214.

2022

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

99241 Office or other outpatient consultation, new or established patient; self-limited or minor problem, 15 min.

99242 low severity problem, 30 min.

99243 moderate severity problem, 45 min.

99244 moderate to high severity problem, 60 min.

99245 moderate to high severity problem, 80 min.

NOTE: Use of these codes (99241-99245) requires the following:

a) Written or verbal request for consultation is documented in the patient chart;

b) Consultant’s opinion as well as any services ordered or performed are documented in the patient chart; and

c) Consultant’s opinion and any services that are performed are prepared in a written report, which is sent to the requesting physician or other

appropriate source (Note: Patients/Parents may not initiate a consultation)

+99354 Prolonged services in office or other outpatient setting, with direct patient contact; first hour (use in

conjunction with time-based codes 99241-99245, 99324-99337, 99341-99350, 90837)

+99355 each additional 30 min. (use in conjunction with 99354)

• Used when a physician or other QHP provides prolonged services beyond the usual service (ie, beyond the typical time).

• Time spent does not have to be continuous.

• Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported

separately.

If reporting your E/M service based on time and not key factors (hx, exam, medical decision making), the physician must reach the

typical time in the highest code in the code set being reported (eg, 99245) before face-to-face prolonged services can be reported

Physician Non-Face-to-Face Services

*For more information on reporting these and other non-face-to-face services see the Care Management fact sheet.

Principal Care Management

1. A single (1) chronic condition expected to last at least 3 months, and that places the patient at significant

risk of hospitalization, acute exacerbation/decompensation, functional decline, or death

2. A condition that requires development, monitoring, or revision of disease-specific care plan,

3. A condition that requires frequent adjustments in the medication regimen and/or the management of the

condition is unusually complex due to comorbidities

4. Ongoing communication and care coordination between relevant practitioners furnishing care may be

reported by different physicians or QHPs in the same calendar month for the same patient

5. Documentation in the patient’s medical record should reflect coordination among relevant managing

clinicians

6. Principal care management services are disease-specific management services. Even if a patient may

have multiple chronic conditions they may receive principal care management if the reporting

physician or other QHP is providing single disease rather than comprehensive care management

99424 Principal care management services, for a single high-risk disease, with the following required elements:

• one complex chronic condition expected to last at least 3 months, and that places the patient at

significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or

death,

• the condition requires development, monitoring, or revision of disease-specific care plan,

• the condition requires frequent adjustments in the medication regimen and/or the management

of the condition is unusually complex due to comorbidities,

• ongoing communication and care coordination between relevant practitioners furnishing care;

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

first 30 minutes provided personally by a physician or other QHP, per calendar month.

+ 99425 each additional 30 minutes provided personally by a physician or other qualified health care

professional, per calendar month (List separately in addition to 99424)

Chronic Care Management

Codes are selected based on the amount of time spent by the physician or qualified health care professional providing

care coordination activities. CPT clearly defines what is defined as care coordination activities. In order to report

chronic care or complex chronic care management codes, you must

1. provide 24/7 access to physicians or other qualified health care professionals or clinical staff;

2. use a standardized methodology to identify patients who require chronic complex care coordination services

3. have an internal care coordination process/function whereby a patient identified as meeting the requirements for

these services starts receiving them in a timely manner

4. use a form and format in the medical record that is standardized within the practice

5. be able to engage and educate patients and caregivers as well as coordinate care among all service professionals, as

appropriate for each patient.

99491 Chronic care management services, provided personally by a physician or other qualified health care

professional, at least 30 minutes of physician or other qualified health care professional time, per calendar

month, with the following required elements:

• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death

of the patient;

• Chronic conditions place the patient at significant risk of death, acute exacerbation or

decompensation, or functional decline;

• Comprehensive care plan established, implemented, revised, or monitored.

(For time spent by the physician directing clinical staff, refer to codes 99490, 99487, 99489 below)

Online Digital Evaluation and Management Service

These are patient-initiated services with physicians or other qualified health care professionals (QHPs) who are allowed to

report E/M services. Online digital E/M services require physician or other QHP’s evaluation, assessment, and management

of the patient and are not for the nonevaluative electronic communication of test results, scheduling of appointments, or

other communication that does not include E/M. These are more appropriate when dealing with a more minor issue or

during a month when you are not coding or providing more robust care thus this time would be reported under another

service like care management.

• Patient must be established (problem can be new)

• Services must be initiated through Health Insurance Portability and Accountability Act (HIPAA)-compliant secure

platforms

• Reported once for the physician’s or other QHP’s (including all in the same group practice) cumulative time during a

seven-day period

• The seven-day period begins with the physician’s or other QHP’s initial, personal review of the patient-generated

inquiry.

• Online digital E/M services require permanent documentation storage (electronic or hard copy) of the encounter.

• Do not report these codes separately if the patient is seen within 7 days of the service for an issue related to the

encounter.

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

• Your date of service will be the date the initiation of the e-visit began or the range of dates it took place because this

service is cumulative time over 7 days.

99421 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time

during the 7 days; 5-10 minutes

99422 11-20 minutes

99423 21 or more minutes

Telephone Care Services

Telephone care must be initiated by the parent, patient or the guardian. The telephone call cannot be related to an E/M

service within the previous 7 days nor can they lead to an appointment within the next 24 hours or soonest available. This is

not telehealth or telemedicine. Your date of service will be date the phone call takes place.

99441 Telephone evaluation and management to patient, parent or guardian not originating from a related E/M service

within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest

available appointment; 5-10 minutes of medical discussion

99442 11-20 minutes of medical discussion

99443 21-30 minutes of medical discussion

Medical Team Conference

99367 Medical team conference by physician with interdisciplinary team of healthcare professionals, patient

and/or family not present, 30 minutes or more

Care Plan Oversight

99339 Care Plan Oversight - Individual physician supervision of a patient (patient not present) in home, domiciliary or

rest home (e.g., assisted living facility) requiring complex and multidisciplinary care modalities involving regular

physician development and/or revision of care plans, review of subsequent reports of patient status, review of

related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care

decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian)

and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan

and/or adjustment of medical therapy, within a calendar month; 15-29 minutes

99340 30 minutes or more

Prolonged Services

99358 Prolonged services without direct patient contact; first hour

+99359 each additional 30 min. (+ designated add-on code, use in conjunction with 99358)

[B]Physician-Directed Non–Face-to-Face Services

Behavioral health integration care management, chronic care management, psychiatric collaborative care management

services and transition care management are reported under the directing physician or other qualified health care

professional, however, the time requirement can be met by clinical staff working under the direction of the reporting

physician or other qualified health care professional. See each code set for details.

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

Behavioral Health Integration Care Management

99484 Care management services for behavioral health conditions, at least 20 minutes of clinical staff time,

directed by a physician or other qualified health care professional, per calendar month, with the following

required elements:

• initial assessment or follow-up monitoring, including the use of applicable validated rating scales;

• behavioral health care planning in relation to behavioral/psychiatric health problems, including

revision for patients who are not progressing or whose status changes;

• facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or

psychiatric consultation; and

• continuity of care with a designated member of the care team.

Tips:

• Reported by the supervising physician or other qualified health care professional.

• The assessment and treatment plan is not required to be comprehensive and the office/practice is not required to

have all the functions of chronic care management (99487, 99489, 99490).

• May be used in any outpatient setting, as long as the reporting professional has an ongoing relationship with the

patient and clinical staff and as long as the clinical staff is available for face-to-face services with the patient.

• Behavioral integration care management (99484) and chronic care management services may be reported by the

same professional in the same month, as long as distinct care management services are performed.

Principal Care Management

99426 Principal care management services, for a single high-risk disease, with the following required

elements:

• one complex chronic condition expected to last at least 3 months, and that places the patient at

significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or

death,

• the condition requires development, monitoring, or revision of disease-specific care plan,

• the condition requires frequent adjustments in the medication regimen and/or the management of

the condition is unusually complex due to comorbidities,

• ongoing communication and care coordination between relevant practitioners furnishing care;

first 30 minutes of clinical staff time directed by physician or other qualified health care professional,

per calendar month.

+ 99427 each additional 30 minutes of clinical staff time directed by a physician or other QHP, per

calendar month

(List separately in addition to code 99426)

Psychiatric Collaborative Care Management Services

99492 Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health

care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other

qualified health care professional, with the following required elements:

• outreach to and engagement in treatment of a patient directed by the treating physician or other qualified

health care professional;

• initial assessment of the patient, including administration of validated rating scales, with the development of an

individualized treatment plan;

• review by the psychiatric consultant with modifications of the plan if recommended;

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

• entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate

documentation, and participation in weekly caseload consultation with the psychiatric consultant; and

• provision of brief interventions using evidence-based techniques such as behavioral activation, motivational

interviewing, and other focused treatment strategies.

99493 Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral

health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or

other qualified health care professional, with the following required elements:

• tracking patient follow-up and progress using the registry, with appropriate documentation;

• participation in weekly caseload consultation with the psychiatric consultant;

• ongoing collaboration with and coordination of the patient's mental health care with the treating physician or

other qualified health care professional and any other treating mental health providers;

• additional review of progress and recommendations for changes in treatment, as indicated, including

medications, based on recommendations provided by the psychiatric consultant;

• provision of brief interventions using evidence-based techniques such as behavioral activation, motivational

interviewing, and other focused treatment strategies;

• monitoring of patient outcomes using validated rating scales; and

• relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment

goals and are prepared for discharge from active treatment.

+ 99494 Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month

of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating

physician or other qualified health care professional (List separately in addition to code for primary procedure)

Care Management Services

Codes are selected based on the amount of time spent by clinical staff providing care coordination activities. CPT clearly

defines what is defined as care coordination activities. In order to report chronic care or complex chronic care

management codes, you must

1. provide 24/7 access to physicians or other qualified health care professionals or clinical staff;

2. use a standardized methodology to identify patients who require chronic complex care coordination services

3. have an internal care coordination process/function whereby a patient identified as meeting the requirements for

these services starts receiving them in a timely manner

4. use a form and format in the medical record that is standardized within the practice

5. be able to engage and educate patients and caregivers as well as coordinate care among all service professionals, as

appropriate for each patient.

99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or

other qualified health care professional, per calendar month, with the following required elements:

• multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;

• chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or

functional decline;

• comprehensive care plan established, implemented, revised, or monitored.

Do not report 99490 for chronic care management services that do not take a minimum of 20 minutes in a calendar

month.

99487 Complex chronic care management services;

• multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

• chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or

functional decline;

• establishment or substantial revision of a comprehensive care plan;

• moderate or high complexity medical decision making;

• 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar

month.

Do not report 99487 for chronic care management services that do not take a minimum of 60 minutes in a calendar

month.

+99489 each additional 30 minutes of clinical staff time directed by a physician or other qualified health

care professional, per calendar month

Complex chronic care management is reported by the physician or qualified health care professional who provides or

oversees the management and coordination of all of the medical, psychosocial, and daily living needs of a patient with a

chronic medical condition. Typical pediatric patients

1. receive three or more therapeutic interventions (eg, medications, nutritional support, respiratory therapy)

2. have two or more chronic continuous or episodic health conditions expected to last at least 12 months (or until death

of the patient) and places the patient at significant risk of death, acute exacerbation or decompensation, or functional

decline

3. commonly require the coordination of a number of specialties and services.

Transition Care Management

99495 Transitional care management (TCM) services with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of

discharge

• Medical decision-making of at least moderate complexity during the service period

• Face-to-face visit, within 14 calendar days of discharge

99496 Transitional care management services with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of

discharge

• Medical decision-making of high complexity during the service period

• Face-to-face visit, within 7 calendar days of discharge

These services are for a patient whose medical and/or psychosocial problems require moderate or high complexity

medical decision-making during transitions in care from an inpatient hospital setting (including acute hospital,

rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled

nursing facility/nursing facility to the patient’s community setting (home, domiciliary, rest home, or assisted living).

TCM commences on the date of discharge and continues for the next 29 days and requires a face-to-face visit, initial

patient contact, and medication reconciliation within specified timeframes. Any additional E/M services provided after

the initial may be reported separately.

Refer to the CPT manual for complete details on reporting care management and TCM services.

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

Psychiatric Diagnostic or Evaluative Interview Procedures

90791 Psychiatric diagnostic interview examination evaluation

90792 Psychiatric diagnostic evaluation with medical services

Psychotherapy

90832 Psychotherapy, 30 min with patient and/or family;

+90833 with medical evaluation and management (Use in conjunction with 99201–99255, 99304–99337, 99341–99350)

90834 Psychotherapy, 45 min with patient and/or family;

+90836 with medical evaluation and management services (Use in conjunction with 99201–99255, 99304–99337, 99341–

99350)

90837 Psychotherapy, 60 min with patient and/or family;

+90838 with medical evaluation and management services (Use in conjunction with 99201–99255, 99304–99337, 99341–

99350)

+90785 Interactive complexity (Use in conjunction with codes for diagnostic psychiatric evaluation [90791, 90792],

psychotherapy [90832, 90834, 90837], psychotherapy when performed with an evaluation and management service

[90833, 90836, 90838, 99201-99255, 99304-99337, 99341-99350], and group psychotherapy [90853])

• Refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include more

difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped

or impaired patients. Typical encounters include:

o Patients who have other individuals legally responsible for their care

o Patients who request others to be present or involved in their care such as translators, interpreters or additional family

members

o Patients who require the involvement of other third parties such as child welfare agencies, schools or probation officers

90846 Family psychotherapy (without patient present), 50 min

90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 min

90849 Multiple-family group psychotherapy

90853 Group psychotherapy (other than of a multiple family group)

• For interactive group psychotherapy use code 90785 in conjunction with code 90853

Other Psychiatric Services/Procedures

+90863 Pharmacologic management, including prescription and review of medication, when performed with

psychotherapy services (Use in conjunction with 90832, 90834, 90837)

• For pharmacologic management with psychotherapy services performed by a physician or other qualified

health care professional who may report E/M codes, use the appropriate E/M codes 99201-99255, 99281-99285, 99304-

99337, 99341-99350 and the appropriate psychotherapy with E/M service 90833, 90836,90838).

90885 Psychiatric evaluation of hospital records, other psychiatric reports, and psychometric and/or projective

tests, and other accumulated data for medical diagnostic purposes

90887 Interpretation or explanation of results of psychiatric, other medical exams, or other accumulated data to

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

family or other responsible persons, or advising them how to assist patient

90889 Preparation of reports on patient’s psychiatric status, history, treatment, or progress (other than for legal

or consultative purposes) for other individuals, agencies, or insurance carriers

Assessment and Testing

Psychological Testing

96130 Psychological testing evaluation services by physician or other qualified health care professional, including

integration of patient data, interpretation of standardized test results and clinical data, clinical decision making,

treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when

performed; first hour

+ 96131 each additional hour (List separately in addition to code 96130)

96136 Psychological or neuropsychological test administration and scoring by physician or other qualified health care

professional, two or more tests, any method; first 30 minutes

+ 96137 each additional 30 minutes (List separately in addition to 96136)

96146 Psychological or neuropsychological test administration, with single automated, standardized instrument via

electronic platform, with automated result only

Assessment of Aphasia

96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function,

language comprehension, speech production ability, reading, spelling, writing, e.g., Boston Diagnostic

Aphasia Examination) with interpretation and report, per hour

Emotional/Behavioral Assessment

96127 Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder

[ADHD] scale), with scoring and documentation, per standardized instrument

Other Qualified Nonphysician Healthcare Professional Services

CPT defines a qualified nonphysician health care professional is a professional who may independently report

services but may not report the physician or other qualified health care professional E/M services. These

include but not limited to speech-language pathologists, physical therapists, occupational therapists, social

workers, or dietitians.

Medical Team Conference

99366 Medical team conference with interdisciplinary team of healthcare professionals, face-to-face with patient and/or

family, 30 minutes or more, participation by a nonphysician qualified healthcare professional

99368 Medical team conference with interdisciplinary team of healthcare professionals, patient and/or family not present,

30 minutes or more, participation by a nonphysician qualified healthcare professional

Telephone Assessment: Nonphysician Healthcare Professional

98966 Telephone assessment and management service provided by a qualified nonphysician healthcare professional to an

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

established patient, parent or guardian not originating from a related assessment and management service provided

within the previous seven days nor leading to an assessment and management service or procedure within the next 24

hours or soonest available appointment; 5-10 minutes of medical discussion

98967 11-20 minutes of medical discussion

98968 21-30 minutes of medical discussion

Online Digital Evaluation and Management Service

Refer to codes 99421-99423 for more details.

The following codes are reported by nonphysician providers who may independently bill such as physical therapists and

psychologists, but are not reported for clinical staff (eg, RN) unless noted in writing by your payer.

98970 Qualified nonphysician health care professional online digital evaluation and management service, for an established

patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

98971 11-20 minutes

98972 21 or more minutes

Health Behavior Assessment and Intervention

96156 Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical

decision making)

96158 Health behavior intervention (HBI), individual, face-to-face; initial 30 minutes

96159 each additional 15 minutes (Report with 96158)

96164 HBI, group (2 or more patients), face-to-face; initial 30 minutes

96165 each additional 15 minutes (Report with 96164)

96167 HBI, family (with the patient present), face-to-face; initial 30 minutes

96168 each additional 15 minutes (Report with 96167)

96170 HBI, family (without the patient present), face-to-face; initial 30 minutes

96171 each additional 15 minutes (Report with 96170)

*Report the family HBI codes only when the intervention is centered around the family. Do not report if the parent is

present because of the age of the patient, but they not involved in the intervention. Refer to the individual or group codes

instead.

Prolonged Clinical Staff Services with Physician or Other Qualified Health Care Professional Supervision

Codes 99415, 99416 are used when a prolonged E/M service is provided in the office or outpatient setting that involves

prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service, as stated in the code

description.

+ 99415 Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management

service in the office or outpatient setting, direct patient contact with physician supervision; first hour

+ 99416 each additional 30 minutes

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

Codes 99415-99416

• Must always be reported in addition to an appropriate office/outpatient E/M service (ie, 99201-99215)

• Require that the physician or qualified health care professional is present to provide direct supervision of the clinical

staff.

• Are used to report the total duration of face-to-face time spent by clinical staff on a given date providing prolonged

services, even if the time spent by the clinical staff on that date is not continuous.

• Are not reported for time spent performing separately reported services other than the E/M service is not counted

toward the prolonged services time.

• Requires a minimum of 45 minutes spent beyond the typical time of the E/M service code being reported. May require

that the clinical staff spend more time if the physician does not meet the time criteria of the E/M service being

reported

• May not be reported in addition to 99354 or 99355.

[B]Miscellaneous Services

99071 Educational supplies, such as books, tapes or pamphlets, provided by the physician for the patient’s education at

cost to the physician

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Codes

• Use as many diagnosis codes that apply to document the patient’s complexity and report the patient’s symptoms and/or

adverse environmental circumstances.

• Once a definitive diagnosis is established, report the appropriate definitive diagnosis code(s) as the primary code, plus any

other symptoms that the patient is exhibiting as secondary diagnoses that are not part of the usual disease course or are

considered incidental.

Anxiety Related Disorders

F06.4 Anxiety disorder due to known physiological condition

F30.8 Other manic episodes

F39 Unspecified mood [affective] disorder

F40.00 Agoraphobia, unspecified

F40.01 Agoraphobia with panic disorder

F40.02 Agoraphobia without panic disorder

F40.10 Social phobia, unspecified

F40.11 Social phobia, generalized

F40.8 Phobic anxiety disorders, other (phobic anxiety disorder of childhood)

F40.9 Phobic anxiety disorder, unspecified

F41.0 Panic disorder [episodic paroxysmal anxiety] without agoraphobia (panic attack)

F41.1 Generalized anxiety disorder (Anxiety reaction)

F41.8 Anxiety depression (mild or not persistent)

F41.9 Anxiety disorder, unspecified

F93.0 Separation anxiety disorder of childhood

Substance Induced Anxiety Disorders

F10.280 Alcohol dependence with alcohol-induced anxiety disorder

F10.980 Alcohol use, unspecified with alcohol-induced anxiety disorder

F12.180 Cannabis abuse with cannabis-induced anxiety disorder

F12.280 Cannabis dependence with cannabis-induced anxiety disorder

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

F12.980 Cannabis use, unspecified with anxiety disorder

F13.180 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced anxiety disorder

F13.280 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced anxiety disorder

F13.980 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic oranxiolytic-induced anxiety disorder

F14.180 Cocaine abuse with cocaine-induced anxiety disorder

F14.280 Cocaine dependence with cocaine-induced anxiety disorder

F14.980 Cocaine use, unspecified with cocaine-induced anxiety disorder

F15.180 Other stimulant abuse with stimulant-induced anxiety disorder

F15.280 Other stimulant dependence with stimulant-induced anxiety disorder

F16.180 Hallucinogen abuse with hallucinogen-induced anxiety disorder

F16.280 Hallucinogen dependence with hallucinogen-induced anxiety disorder

F16.980 Hallucinogen use, unspecified with hallucinogen-induced anxiety disorder

F18.180 Inhalant abuse with inhalant-induced anxiety disorder

F18.280 Inhalant dependence with inhalant-induced anxiety disorder

F18.980 Inhalant use, unspecified with inhalant-induced anxiety disorder

F19.280 Other psychoactive substance dependence with psychoactive substance-induced anxiety disorder

F19.980 Other psychoactive substance use, unspecified with psychoactive substance-induced anxiety disorder

Depression/Depressive Disorders

F34.1 Dysthymic disorder (depressive personality disorder, dysthymia neurotic depression)

F32.9 Major depressive disorder, single episode, unspecified

F32.A Depression, unspecified

Feeding and Eating Disorders/Elimination Disorders

F50.89 Eating disorders, other (psychogenic vomiting)

F50.9 Eating disorder, unspecified

F98.0 Enuresis not due to a substance or known physiological condition

F98.1 Encopresis not due to a substance or known physiological condition

F98.3 Pica (infancy or childhood)

Impulse Disorders

F63.9 Impulse disorder, unspecified

Neurodevelopmental Disorders

F70 Mild intellectual disabilities

F71 Moderate intellectual disabilities

F72 Severe intellectual disabilities

F73 Profound intellectual disabilities

F79 Unspecified intellectual disabilities

F80.4 Speech and language developmental delay due to hearing loss (code also hearing loss)

F80.89 Other developmental disorders of speech and language

F80.9 Developmental disorder of speech and language, unspecified

F95.0 Transient tic disorder

F95.1 Chronic motor or vocal tic disorder

F95.2 Tourette’s disorder

F95.9 Tic disorder, unspecified

Obsessive-Compulsive and Related Disorders

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

F63.3 Trichotillomania/hair plucking

F63.9 Impulse disorder, unspecified

F98.8 Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence (nail-

biting, nose-picking, thumb-sucking)

Somatoform Disorders

F45.41 Pain disorder exclusively related to psychological factors

F45.42 Pain disorder with related psychological factors(code also associated acute or chronic pain (G89.-)

F45.8 Other somatoform disorders (psychogenic hyperventilation, teeth grinding)

Trauma and Stressor-Related Disorders

F43.0 Acute stress reaction

F43.20 Adjustment disorder, unspecified

F43.22 Adjustment disorder with anxiety

F43.23 Adjustment disorder with mixed anxiety and depressed mood

F43.29 Adjustment disorder with other symptoms

F43.8 Other reactions to severe stress

F43.9 Reaction to severe stress, unspecified

Substance-Related and Addictive Disorders:

If a provider documents multiple patterns of use, only one should be reported. Use the following hierarchy: use–abuse–

dependence (eg, if use and dependence are documented, only code for dependence).

When a minus symbol (-) is included in codes F10–F17, a last digit is required. Be sure to include the last digit from the

following list:

0 anxiety disorder

2 sleep disorder

8 other disorder

9 unspecified disorder

Alcohol

F10.10 Alcohol abuse, uncomplicated (alcohol use disorder, mild)

F10.20 Alcohol dependence, uncomplicated

F10.21 Alcohol dependence, in remission

Cannabis

F12.10 Cannabis abuse, uncomplicated (cannabis use disorder, mild)

F12.18- Cannabis abuse with cannabis-induced

F12.19 Cannabis abuse with unspecified cannabis-induced disorder

F12.20 Cannabis dependence, uncomplicated

F12.21 Cannabis dependence, in remission

F12.90 Cannabis use, unspecified, uncomplicated

Sedatives

F13.10 Sedative, hypnotic or anxiolytic abuse, uncomplicated (use disorder, mild)

F13.129 Sedative, hypnotic or anxiolytic abuse with intoxication, unspecified

F13.14 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced mood disorder

F13.18- Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

F13.21 Sedative, hypnotic or anxiolytic dependence, in remission

F13.90 Sedative, hypnotic, or anxiolytic use, unspecified, uncomplicated

Stimulants (eg, Caffeine, Amphetamines)

F15.10 Other stimulant (amphetamine-related disorders or caffeine) abuse, uncomplicated (use disorder, mild)

F15.14 Other stimulant (amphetamine-related disorders or caffeine) abuse with stimulant-induced mood disorder

F15.19 Other stimulant (amphetamine-related disorders or caffeine) abuse with unspecified stimulant-induced

disorder

F15.20 Other stimulant (amphetamine-related disorders or caffeine) dependence, uncomplicated

F15.21 Other stimulant (amphetamine-related disorders or caffeine) dependence, in remission

F15.90 Other stimulant (amphetamine-related disorders or caffeine) use, unspecified, uncomplicated

Nicotine (eg, Cigarettes)

F17.200 Nicotine dependence, unspecified, uncomplicated (tobacco use disorder, mild, moderate or severe)

F17.201 Nicotine dependence, unspecified, in remission

F17.203 Nicotine dependence unspecified, with withdrawal

F17.210 Nicotine dependence, cigarettes, uncomplicated

F17.211 Nicotine dependence, cigarettes, in remission

F17.213 Nicotine dependence, cigarettes, with withdrawal

Trauma- and Stressor-Related Disorders

F43.22 Adjustment disorder with anxiety

F43.23 Adjustment disorder with mixed anxiety and depressed mood

F43.25 Adjustment disorder with mixed disturbance of emotions and conduct

F43.29 Adjustment disorder with other symptoms

F43.0 Acute stress reaction

F43.8 Other reactions to severe stress

F43.9 Reaction to severe stress, unspecified

Other

F07.81 Postconcussional syndrome

F07.89 Personality and behavioral disorders due to known physiological condition, other

F07.9 Personality and behavioral disorder due to known physiological condition, unspecified

F45.41 Pain disorder exclusively related to psychological factors

F45.42 Pain disorder with related psychological factors(code also associated acute or chronic pain (G89.-)

F48.8 Other specified nonpsychotic mental disorders (Neurasthenia)

F48.9 Nonpsychotic mental disorder, unspecified

F93.8 Childhood emotional disorders, other

Symptoms, Signs, and Ill-Defined Conditions

Use these codes in absence of a definitive mental diagnosis or when the sign or symptom is not part of the disease course or

considered incidental.

G44.201 Tension-type headache, unspecified, intractable

G44.209 Tension-type headache, unspecified, not intractable

G44.221 Chronic tension-type headache, intractable

G44.229 Chronic tension-type headache, not intractable

G47.9 Sleep disorder, unspecified

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

K59.00 Constipation, unspecified

N39.44 Nocturnal enuresis

R00.0 Tachycardia, unspecified

R03.0 Elevated blood-pressure reading, without diagnosis of hypertension

R06.02 Shortness of breath

R06.4 Hyperventilation

R07.9 Chest pain, unspecified

R10.0 Acute abdomen pain

R11.0 Nausea

R11.11 Vomiting without nausea

R11.2 Nausea with vomiting, unspecified

R12 Heartburn

R14.1 Gas pain

R14.2 Eructation

R14.3 Flatulence

R19.7 Diarrhea, unspecified

R19.8 Other specified symptoms and signs involving the digestive system and abdomen

R45.0 Nervousness

R45.82 Worries

R45.83 Excessive crying of child, adolescent or adult

R45.89 Other symptoms and signs involving emotional state

R51 Headache

R63.3 Feeding difficulties

R63.4 Abnormal weight loss

R63.5 Abnormal weight gain

R68.89 Other general symptoms and signs

T56.0X1- Toxic effect of lead and its compounds, accidental (unintentional), initial encounter (requires a 7

digit –refer to the ICD manual)

Z Codes

Z codes represent reasons for encounters. Categories Z00–Z99 are provided for occasions when circumstances other than a

disease, injury, or external cause classifiable to categories A00–Y89 are recorded as 'diagnoses' or 'problems'. This can arise

in 2 main ways.

(a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive

limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination

(immunization), or to discuss a problem is in itself not a disease or injury.

(b) When some circumstance or problem is present which influences the person’s health status but is not in itself a current

illness or injury.

(c) When a social determinant of health is identified during an encounter and it is either addressed or shown to complicate

the encounter, it should be coded.

Z13.4 Encounter for screening for certain developmental disorders in childhood (not for routine screen)

Z13.89 Encounter for screening for other disorder (anxiety)

Z59.00 Homelessness unspecified

Z59.5 Extreme poverty

Z59.6 Low income

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided

 Indicates CPT allows as a telemedicine service

Z59.7 Insufficient social insurance and welfare support

Z59.8 Other problems related to housing and economic circumstances

Z60.3 Acculturation difficulty

Z60.4 Social exclusion and rejection

Z60.5 Target of (perceived) adverse discrimination and persecution

Z60.9 Problem related to social environment, unspecified

Z62.21 Foster care status (child welfare)

Z62.6 Inappropriate (excessive) parental pressure

Z62.810 Personal history of physical and sexual abuse in childhood

Z62.811 Personal history of psychological abuse in childhood

Z62.812 Personal history of neglect in childhood

Z62.819 Personal history of unspecified abuse in childhood

Z62.820 Parent-biological child conflict

Z62.821 Parent-adopted child conflict

Z62.822 Parent-foster child conflict

Z63.31 Absence of family member due to military deployment

Z63.32 Other absence of family member

Z63.4 Disappearance and death of family member

Z63.5 Disruption of family by separation and divorce

Z63.72 Alcoholism and drug addiction in family

Z63.8 Other specified problems related to primary support group

Z65.3 Problems related to other legal circumstances

Z71.89 Counseling, other specified

Z71.9 Counseling, unspecified

Z72.0 Tobacco use

Z81.0 Family history of intellectual disabilities (conditions classifiable to F70–F79)

Z81.8 Family history of other mental and behavioral disorders

Z86.2 Personal history of diseases of the blood and blood-forming organs and certain disorders involving the

immune mechanism

Z86.39 Personal history of other endocrine, nutritional and metabolic disease

Z86.59 Personal history of other mental and behavioral disorders

Z86.69 Personal history of other diseases of the nervous system and sense organs

Z87.09 Personal history of other diseases of the respiratory system

Z87.19 Personal history of other diseases of the digestive system

Z87.798 Personal history of other (corrected) congenital malformations

Z87.820 Personal history of traumatic brain injury

Z88.9 Allergy status to unspecified drugs, medicaments and biological substances status

Z91.010 Allergy to peanuts

Z91.013 Allergy to seafood

Z91.030 Bee allergy status

Z91.038 Other insect allergy status

Z91.09 Other allergy status, other than to drugs and biological substances

Z91.14 Patient's other noncompliance with medication regimen

Z91.19 Patient's noncompliance with other medical treatment and regimen