Neurology & Pain Management Coding Alert

Question: I've heard that in order for us to bill 96110, the report section should be included in the medical record. What are the requirements for reporting 96110?

Illinois Subscriber

Answer: In order to properly report 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report), your supporting documents need to show that your neurologist reviewed and interpreted a standardized test/tool. The report will be scored as either "normal" or "abnormal" on the chart.

Your neurologist must also indicate that he reviewed and discussed the results with the patient or a family member. Keeping a copy of the actual questionnaire in the patient's record is probably good practice as well. Make sure the documentation refers to the test by name, however -- that way an auditor will see that your neurologist used a qualifying test.

Important: Notice that you won't see codes for administering or scoring the report, because those duties are usually assigned to a nurse or other trained nonphysician personnel, and the relative value units (RVUs) reflect that. Often the physician himself does not actually administer these tests as noted also by the "0" physician work valuation in the Medicare fee schedule.

"Because an office nurse or other trained nonphysician personnel typically performs the service, this relative value reflects only the practice expense of the office staff and nurses, the cost of the materials, and professional liability -- there is no physician work value published on the Medicare physician fee schedule for this code," according to the American Academy of Pediatrics.

Therefore, your practice's ancillary staff can administer and score the test. The physician then can review and interpret the test and reports on these findings.

Tip: You may also want to wait to bill 96110 until the date the test is actually discussed with the patient or family member.