HCPCS T1025: Intensive Multidisciplinary Pediatric Clinic Services, Per Diem

HCPCS Level II code T1025 represents a per diem payment for intensive, extended multidisciplinary clinic services provided to children with complex medical, physical, mental, and psychosocial impairments. Nationwide, this code signals support for coordinated, high-touch care models that address multiple domains of need in pediatric populations and can affect access to specialized clinic-based programs.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise review of what T1025 represents clinically and operationally, alongside a national perspective on payer coverage approaches. The publication outlines typical utilization contexts, common billing practices, and the clinical settings where the code is most relevant.

The report provides benchmarks and policy-relevant context for clinic-based multidisciplinary pediatric care, including per-diem service structuring and implications for program design. It also highlights areas where payers vary in coverage and documentation expectations. Data not provided in the input (such as specific payer rates, taxonomies, or ICD-10 pairings) are noted as unavailable and are not fabricated. This summary equips administrators, billing professionals, and policy stakeholders with a clear, national-level understanding of HCPCS Level II code T1025 and its role in supporting complex pediatric clinic services.

Billing Code Overview

HCPCS Level II code T1025 describes intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, mental and psychosocial impairments, per diem. This service is delivered by a coordinated team of clinicians across specialties and is intended to address complex, multi-domain needs through prolonged, structured interventions.

Service type: Intensive, extended multidisciplinary pediatric clinic services
Typical site of service: Clinic setting (ambulatory specialty clinic or multidisciplinary pediatric center)

Data not available in the input.

Clinical Context

A school-age child with complex congenital heart disease, developmental delay, and comorbid behavioral health needs presents for an intensive, multidisciplinary clinic day. The child has frequent medical fragility: gastrostomy tube dependence, tracheostomy with ventilator support, and seizure disorder requiring neurology follow-up. The clinic visit is scheduled as a per diem multidisciplinary service to coordinate medical, developmental, nursing, nutrition, respiratory, and psychosocial care.

Workflow:

Pre-visit chart review and care-plan coordination by a pediatric complex care nurse and clinic coordinator.
Arrival and triage in the clinic: vital signs, ventilator check by respiratory therapist, and enteral feeding review by nutritionist.
Sequential multidisciplinary evaluations: pediatrician/complex care physician conducts medical assessment; pediatric pulmonologist or respiratory therapist evaluates ventilator/tracheostomy status; pediatric dietitian assesses gastrostomy feeding tolerance and growth; pediatric physical/occupational therapist assesses mobility and adaptive equipment needs; behavioral health clinician evaluates psychosocial stressors and caregiver supports.
Multidisciplinary case conference during the per diem session to synthesize findings, update the care plan, reconcile medications, and arrange home health, durable medical equipment, and school-based services.
Documentation: a consolidated multidisciplinary note and individualized care plan saved to the medical record, with clear problem list, orders, and follow-up appointments.
Billing: the per diem intensive service is reported with T1025 for the clinic day; appropriate modifiers are appended when required to indicate unusual work, partial services, or payment exceptions; diagnosis codes reflecting the child’s primary medical complexity are reported on the claim to support medical necessity.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	When the multidisciplinary day required substantially greater work or intensity than typical per diem (rare; document rationale).
`23`	Unusual anesthesia	Not typically used with `T1025`; only when separate anesthesia services were required during the clinic day.
`52`	Reduced services	When the full multidisciplinary per diem service was partially provided (e.g., early discharge during the clinic day).
`53`	Discontinued service	When the clinic per diem was started but discontinued due to patient instability or transfer.
`54`	Surgical care only	Not generally applicable; used when surgical care was the only component and billed separately.
`55`	Postoperative management only	Use if only postoperative follow-up occurred within the per diem day and other multidisciplinary components were not provided.
`56`	Preoperative management only	Use if only preoperative evaluation was provided within the clinic day.
`59`	Distinct procedural service	When another distinct, separately billable service was provided the same day and must be distinguished from the per diem.
`62`	Two surgeons	Applicable only if two surgeons billed separately for distinct surgical services during the same episode associated with the clinic visit.
`AS`	Physician assistant or nurse practitioner-participating in service	When an assistant-at-surgery or advanced practitioner provided components billed under supervision rules during the clinic day.
`CQ`	Service furnished as part of qualified nonphysician health care professional shortage area (HPSA) or other site-specific programs	When applicable for payment adjustments tied to specific programs.
`QK`	Medical direction of two, three, or four concurrent anesthesia procedures	Only relevant if anesthesia services were furnished and medical direction rules apply.
`QX`	CRNA service with medical direction	Only relevant if a CRNA provided anesthesia services during the clinic-associated procedure.
`QY`	Medical direction of one CRNA by an anesthesiologist	Only relevant when anesthesia team billing interactions occur in conjunction with a procedure tied to the clinic day.

Taxonomy Code	Specialty	Notes
`207Q00000X`	Pediatrics	Primary complex care physician overseeing the per diem multidisciplinary service.
`2080P0206X`	Pediatric Pulmonology	Evaluates tracheostomy/ventilator needs and pulmonary clearance.
`2080P0204X`	Pediatric Cardiology	Manages congenital heart disease components when present.
`251B00000X`	Nutritionist / Registered Dietitian	Manages enteral feeding, growth, and nutrition plan.
`332B00000X`	Pediatric Nursing (Home/Complex Care)	Provides nursing assessment, medication reconciliation, and care coordination documentation.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z74.01`	Bed confinement status	Reflects high care needs and home care dependence often seen in children requiring per diem multidisciplinary services.
`Z99.11`	Dependence on respirator [ventilator]	Common in children with tracheostomy and ventilator support who attend intensive multidisciplinary clinics.
`Z93.1`	Gastrostomy status	Indicates enteral feeding dependence and informs nutritional and nursing components of the per diem visit.
`Q21.1`	Atrial septal defect	Example of congenital heart disease contributing to medical complexity and need for specialized multidisciplinary evaluation.
`G40.909`	Epilepsy, unspecified, not intractable, without status epilepticus	Seizure disorders commonly require neurology input during complex care clinic days.
`F82`	Specific developmental disorder of motor function (developmental coordination disorder)	Represents developmental impairment that triggers therapy and rehabilitation interventions within the multidisciplinary visit.
`Z55.9`	Problems related to education and literacy, unspecified	Captures psychosocial and school-related care coordination addressed during the clinic day.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity	Used for individual physician encounters within the multidisciplinary day when separate E/M visits are documented and billed in addition to the per diem where allowed.
`99487`	Complex chronic care coordination services, first hour of clinical staff time directed by a physician or other qualified health care professional per calendar month	May be billed in care coordination programs distinct from the per diem when monthly time-based complex chronic care management is provided.
`99489`	Complex chronic care coordination services, each additional 30 minutes per calendar month	Used to report additional time beyond the first hour for complex care management when applicable.
`93503`	Insertion and repositioning of single-lumen central venous catheter, not commonly part of the clinic day but related to complex care procedures	Relevant when clinic-based procedures for vascular access are performed as part of the child’s comprehensive care (billing depends on site and payer rules).
`94640`	Pressurized or non-pressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes	Performed by respiratory therapy during the clinic day for acute airway needs or diagnostics related to pulmonary management.

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Summary & Overview