Billing & Coding

Iowa EPSDT Services

EPSDT screening visits, also known as well-child visits or periodic health supervision visits, are billed using comprehensive preventive medicine CPT services codes coupled with ICD-10 diagnostic codes.

Services billed under these codes are specified by age in the Iowa Periodicity Schedule. These services include:

  • Comprehensive health, nutrition and developmental history
  • Review of physical, mental health and developmental status
  • Review of family risk factors, including family stress and maternal depression
  • Unclothed physical exam
  • Immunization history
  • Oral health screening
  • Age-appropriate anticipatory guidance
  • Ordering appropriate immunizations or laboratory/diagnostic procedures

Baby-Screening-2

EPSDT Screening

Comprehensive Preventive Medicine Current Procedural Terminology (CPT) Codes

Age Range New Patients Established Patients
<1 year 99381 99391
1-4 years 99382 99392
5-11 years 99383 99393
12-17 years 99384 99394
18-21 years 99385 99395

Additional Codes:

Additional codes may be billed on the same date of service as the comprehensive preventive codes. They include:

  • Laboratory testing
  • Administration of vaccines
  • Objective developmental, behavior and mental health screening

Referral:

Add the U1 modifier to the screening code where a condition identified during the screen results in a referral for treatment.

Medical group

Developmental and Mental Health Care Billing and Coding

CPT codes for billing standardized screening and assessment of developmental, social-emotional, mental health or family risks are as follows:

Developmental and Mental Health Surveillance: 
Surveillance of a child’s development, behavior, social-emotional status and family risk factors is considered to be an integral part of the EPSDT screening exam and, as such, cannot be billed as an independent service.

Developmental Screening: 
Use of a standardized developmental screening tool with interpretation and report, such as the recommended ASQ-3, may be billed in addition to the preventive medicine services code or any other evaluation and management service. In order for the test to be billed as a separate service, the interpretation and report must be a significant, distinct service. Use the limited development testing code: 96110

Autism Screening: 
Use of a standardized autism screening tool with interpretation and report, such as the recommended M-CHAT R/F, may be billed in addition to the preventive medicine services code or any other evaluation and management service. In order for the test to be billed as a separate service, the interpretation and report must be a significant, distinct service. Use the limited development testing code: 96110

Caregiver Depression Screening: 
Use of a standardized caregiver depression screening tool with interpretation and report, such as the recommended Edinburgh Postnatal Depression Scale or the PHQ-9, may be billed as a separate service. Use code: 99420

Please note that the 2-question PHQ-2 is considered surveillance and a part of the regular EPSDT screening exam. As such, it may not be billed as an independent service.

Adolescent Depression Screening: 
Use of a standardized depression screening tool with interpretation and report, such as the recommended PHQ-9, may be billed as a separate service. Use code: 96127

Please note that the 2-question PHQ-2 is considered surveillance and a part of the regular EPSDT screening exam. As such, it may not be billed as an independent service.

Alcohol and Drug Use Screening: 
Use of a standardized alcohol and drug use screening tool with interpretation and report, such as the recommended CRAFFT, may be billed as a separate service. Use code 96110

Coding Decisions

Emotional and behavioral vs. developmental assessment.

Assistance in deciding on appropriate CPT billing codes for emotional and behavioral assessment is provided by the American Academy of Pediatrics. Find the AAP Coding Corner article online in the January 2015 issue of AAP News.

ICD-10 Diagnostic Code Set

Coding change reminder.

Include the appropriate diagnostic code with the CPT code when billing for EPSDT screening services. Use of the new ICD-10 diagnostic code set went into effect October 1, 2015. Additional information on the coding changes is available from Medicaid and from the CDC.

Coding Strategies

Assessment and diagnosis of developmental, behavioral and social-emotional concerns.

Providers are encouraged to use ICD-10 diagnostic codes whenever those codes are appropriate and reasonable. However, DSM IV psychiatric diagnoses sometimes do not fit well for the problems of young children and their families, and the mental health interventions to serve them.

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-3) from Zero to Three provides a promising practice model for the assessment of infants, young children and parent-child relationships. However, many payers do not yet recognize DC: 0-3 coding alone.

Have questions?

On April 1, 2016, pending final federal approval, the Iowa Department of Human Services (DHS) will be transitioning most Iowa Medicaid members to a new managed care program called IA Health Link. Until the transition occurs, questions should be directed to Provider Services at:

800-338-7909 (Toll free)
515-256-4609 (Des Moines area)
515-725-1155 (Fax)

Provider Services
P.O. Box 36450
Des Moines, IA 50315

For more information regarding the Iowa Medicaid transition to managed care, please read the IA Health Link Managed Care Program Provider Toolkit or the IA Health Link Frequently Asked Questions. You will also find more provider-specific information regarding the managed care transition on the Medicaid Modernization web page.

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