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EPSDT Coding Guide 2021 | TN Practice Matters

Last update: April 15, 2021

An Early Periodic Screening, Diagnosis and Treatment (EPSDT) screening is complete when the 7 components have been completed. Claims will be paid at the provider’s EPSDT rate only if the appropriate codes and EP modifier (example: 25 and 59) are submitted when billing 2 different codes in 1 visit. Visit the Tennessee American Academy of Pediatrics (TNAAP) website to get more billing codes that are used for a preventive screening visit. TNAAP’s EPSDT and Coding program provide 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 held regionally. For more information on these resources, please visit tnaap.org/coding.

Early Periodic Screening, Diagnosis and Treatment (EPSDT) 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
1–4

Z00.121

Z00.129

99383

99393

Late childhood

5–11

Z00.121

Z00.129

99384

99394

Adolescent
12–17

Z00.121

Z00.129

99385

99395

Adult
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 1 screening tool administered during a visit, as well as a sick visit and an EPSDT visit on same day. 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.

CPT® is a registered trademark of the American Medical Association.