EPSDT Coding Guide

Last update: October 2, 2020

An EPSDT screening is complete when the seven components have been finished. Claims will be paid at the provider’s EPSDT rate only if the appropriate codes and EP modifier (e.g., 25 and 59) are submitted when billing two different codes in one visit. Visit tnaap.org to get more billing codes that are used for a preventive screening visit. The Tennessee American Academy of Pediatrics’ (TNAAP) EPSDT and Coding program provides training and educational resources FREE of charge to help you improve the quality of preventive health screens. TNAAP also offers annual EPSDT and Coding Update trainings that are held regionally. For more information on these resources, please visit tnaap.org/coding.

EPSDT Coding Guide

The Early Periodic Screening, Diagnosis and Treatment (EPSDT) benefit is a program of checkups and treatment and/or referrals for needed services for all TennCare-eligible children, birth through age 20. These services make sure infants, children, teens and young adults receive the health care they need in Tennessee.

 

New Patient CPT® Code

Established

Patient CPT Code

Age

ICD-10-CM Codes

99381

99391

Infant < 1 year

Z00.110 – Health exam under 8 days

Z00.111 – Health exam 8-28 days

Z00.121 – Routine exam with abnormal findings

Z00.129 – Routine exam without abnormal findings

99382

99392

Early childhood –
Ages 1-4

Z00.121

Z00.129

99383

99393

Late Childhood –

Ages 5-11

Z00.121

Z00.129

99384

99394

Adolescent – Ages 12-17

Z00.121

Z00.129

99385

99395

Adult – Ages 18-39

Z00.00 – General adult exam without abnormal findings

Z00.01 – General adult exam with abnormal findings

Newborn Codes

99460 – Initial E/M normal newborn in the hospital or birthing center

99461 – Initial E/M normal newborn in other than a hospital or birthing center

99463 –Initial E/M normal newborn admitted and discharged on the same day

*Report ICD-10 Code Z00.110

         

 

It is appropriate to bill for more than one screening tool administered during a visit as well as a sick visit and an EPSDT visit on same day. Simply append Modifier 25 to E/M visit.

When reporting the health risk assessment codes, 96160 and 96161, with developmental screening and/or

emotional/behavioral screening, Modifier 59 should be append­ed to the health risk assessment code.