Published Originally by AAPC Healthcare Business Monthly: https://www.aapc.com/
Correct coding of this preventive service ensures practitioners can give their patients the care they need.
The U.S. Preventive Services Task Force (USPSTF) published recommendations in October 2022 and June 2023 in response to the mental health crisis that continues to affect adolescents and adults in the country regarding screening, diagnosing, and treating anxiety.
Mental health disorders, such as anxiety, plague millions of adolescents and adults in the United States. The Anxiety & Depression Association of America (ADAA) states that 6.8 million adults, or 3.1 percent of the population, are affected by generalized anxiety disorder (GAD), and 15 million adults, or 7.1 percent of the population, are affected by social disorders. Drilling down deeper, anxiety disorders affect 31.9 percent of teens between 13 and 18 years old. A 2020 National Survey of Children’s Health (NSCH) showed that 7.8 percent of children ages 3 to 17 had a current anxiety disorder, with 0.7 percent suffering severe anxiety. These numbers increased significantly during the COVID-19 pandemic.
The USPSTF recommends screening for anxiety disorders in adults 64 years or younger, including pregnant and postpartum women and children and adolescents aged 8 to 18 years because “there is a high certainty that the net benefit is substantial” (Grade B). With these screenings likely on the rise, let’s look at how to code them.
Anxiety disorder comprises a group of related conditions characterized by excessive fear or worry that present as emotional and physical symptoms. When you review the ICD-10-CM code book or the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition), you will notice the various anxiety disorders listed, which include (to name just a few):
- generalized anxiety disorder (F41.1)
- social anxiety disorder (F40.1x)
- panic disorder (F41.0)
- separation anxiety disorder (F93.0)
- phobias (F40.2x)
- selective mutism and anxiety not otherwise specified (F41.9)
Keep in mind that anxiety disorders often do not come alone; patients often have other associated mental health conditions such as depression. The USPSTF recognizes that anxiety may be a comorbid condition (CC) to disorders such as depression, eating disorders, and attention deficit hyperactivity disorder (ADHD).
Differences in the overlap pattern indicate that adolescents with depression are more likely to exhibit comorbid anxiety than the converse. Moreover, evidence indicates that children depressed with comorbid anxiety, specifically GAD, have a higher risk of suicide than children with pure anxiety disorders.
Primary Care Providers’ Role in Screening
Mental health conditions in children and adolescents may present as physical symptoms concurrently, giving primary care physicians opportunities to screen for one or more conditions. However, the USPSTF states in its recommendations that anxiety disorders are often unrecognized in primary care settings, and years-long delays in treatment initiation occur. Coupled with research from the ADAA showing that untreated teenagers with anxiety disorders are at higher risk for long-term anxiety issues and problems in school and at social events, it is clear this at-risk population is missing much-needed treatment.
The USPSTF recommendations mean primary care providers now have an opportunity during annual wellness visits to screen for these conditions. These visits are comprehensive preventive medicine evaluations and management (E/M) of an individual. CPT® code selection is based on whether the patient is new or established and the patient’s age. The Preventive Medicine Services codes are as follows.
- 99383 … late childhood (age 5 through 11 years)
- 99384 … adolescent (age 12 through 17 years)
- 99385 … 18-39 years
- 99386 … 40-64 years
- 99393 … late childhood (age 5 through 11 years)
- 99394 … adolescent (age 12 through 17 years)
- 99395 … 18-39 years
- 99396 – 40-64 years
Note: Medicare annual wellness visits are reported with HCPCS Level II G codes (G0438-G0439). As of October 2023, the Centers for Medicare & Medicaid Services (CMS) had not added anxiety screening to its list of covered preventive services.
If the patient’s complaints are significant enough to require additional work, then the provider may be able to separately bill an appropriate E/M service (CPT® codes 99202-99215). You would append the E/M code with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. Documentation must show the additional work the provider performed was above and beyond what is typically performed in the preventative medicine service.
If warranted, primary care providers may initiate behavioral health integration services, as well, reported with the following Psychiatric Collaborative Care Management Services codes:
- 99492 Initial psychiatric collaborative care management, first 70 minutes …
- 99493 Subsequent psychiatric collaborative care management, first 60 minutes …
- +99494 Initial or subsequent psychiatric collaborative care management, each additional 30 minutes …
- Participation in weekly caseload consultation with the psychiatric consultant;
- Ongoing collaboration with and coordination of the patient’s mental healthcare with the treating physician or other qualified healthcare 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.
These services include collaboration between the treating (billing) practitioner (primary care provider) and other providers such as a psychiatric consultant (trained in psychiatry and qualified to prescribe medication), behavioral healthcare manager (social worker, nurse), and the patient. The primary care provider/team observes and adjustments treatment, medications, and referrals as they see fit. Documentation should include all pertinent care team communications.
Social and Economic Risk Factors
Many social and economic risk factors contribute to the different types of anxiety. Risk factors include genetic, biological, environmental, and individual factors (e.g., age, sex, gender identity, sexual orientation, genetic predisposition). These social and economic factors can be captured in the medical record and coded using the ever-expanding Z code section in ICD-10-CM for social determinants of health (SDOH), which are defined by the Centers for Disease Control and Prevention (CDC) as “nonmedical factors that influence healthcare.”
Per ICD-10-CM guidelines, coding professionals may utilize documentation of social information from social workers, community health workers, case managers, or nurses if their documentation is included in the official medical record.
The USPSTF states in its recommendation summary, “Some instruments that are used for screening for anxiety disorders were initially developed for purposes other than screening, such as supporting diagnosis, assessing severity, or evaluating response to treatment.” This makes anxiety screening tools alone insufficient to diagnose anxiety disorders. A confirmatory diagnostic assessment and follow-up are needed if the screening test is positive for anxiety, according to the USPSTF.
Providers should report the appropriate screening diagnosis codes that explain the final diagnosis, as well as the episode of care. Applicable screening diagnosis codes include:
- Z13.3 Encounter for screening examination for mental health and behavioral disorders
- Z00.121 Encounter for routine child health examination with abnormal findings (This dx code is used with codes 99382-99384, 99392-99394)
- Z00.129 Encounter for routine child health examination without abnormal findings (This dx code is used with codes 99382-99384, 99392-99394)
- Z00.00 Encounter for general adult medical examination without abnormal findings (This dx code is used with codes 99385, 99395)
- Z00.01 Encounter for general adult medical examination with abnormal findings; Use additional code to identify abnormal findings (This dx code is used with codes 99385 and 99395)
Documentation should include status updates to therapy and medication regimens, any side effects, and medication changes. If there is non-compliance to medication, it is important that the diagnosis codes are added to support this (Z91.1x) and the drug that identifies underdosing (T36-T50). Treatment/care plans should be updated accordingly to support mental necessity of ongoing services.
Anxiety screening is the first step in helping patients get the help they need. Treatment may include psychotherapy, pharmacotherapy, cognitive therapy, or a combination of treatments. All patients who test positive should be able to get the necessary treatment they need. Early prevention is always the best medicine, and with these latest USPSTF recommendations, primary care providers have the opportunity to save lives.