Pediatric Coding Alert

Hint: Use modifier -25 to unlock E/M-96110 reimbursement

Stop bundling developmental testing into your E/M code when your pediatrician performs the service during well-check encounters. Instead, report CPT 96110 and watch your reimbursement possibly increase by about $100.

A routine check, a concern, or a prior condition may trigger your pediatrician to test a child's development. The following examples show you how to boost your reimbursement with appropriate E/M service and developmental screening codes.

1. Pediatrician Discovers a Problem at a Sick Visit

If your pediatrician performs developmental screening during an office visit, you should report both services.

Scenario: A parent presents with her 2-year-old child for suspected delayed language development. The pediatrician performs a history, evaluation and medical decision-making in which he determines that the infant requires developmental testing. He questions the mother about the infant's responses and behaviors using the Denver Developmental Screening Test II (DDST-II).

You should submit 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) for limited developmental testing. "Code 96110 includes interpreting and reporting a multitude of tests, such as the DDST-II or the Early Language Milestone Screen," says
David I. Berland, MD, American Academy of Child and Adolescent Psychiatry representative to the AMA CPT Advisory Committee.

You should also report the problem-related visit. Use the appropriate-level E/M code, such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). The modifier tells the payer that the office visit is a separately identifiable service from the screening.

Good news: You should collect payment for both your E/M service and 96110 because carriers typically cover both services.

Even though Medicare pays 96110 at $13.82 (geographically unadjusted rate for 0.37 relative value units), some carriers pay much more. For those payers that cover developmental testing, "reimbursement is typically around $100 or more," says Ellen Harrington-Kane, MS, HSM, OTR/L, medical rehabilitation services senior director at Easter Seals in Chicago in Billing FAQs (www.affiliate.easterseals.com/site/DocServer/BillingFAQs.doc?docID=2761).

Payment, however, is inconsistent. "Insurers in Missouri typically don't cover 96110," Berland says.
Don't assume that noncoverage equals nonpayment. If a service is noncovered, the patient can be balance-billed. If the insurer considers it bundled or included in the E/M code, then you cannot balance-bill it.

2. Physician Screens During Routine Physical

Does your pediatrician perform routine developmental screenings at well visits? Take this opportunity to bill both services.

Example: A father presents with his 4-year-old son for the child's annual physical. The pediatrician performs an age-appropriate re-evaluation and management and also uses the Parents' Evaluation of Developmental Status (PEDS) to measure the child's developmental progress.

In this case, you should report the age-specific preventive medicine service and the developmental testing. Submit 99392-25 (Periodic comprehensive preventive medicine re-evaluation and management of an individual ...; early childhood [age 1 through 4 years]) and 96110 if your payer requires modifier -25 with preventive medicine visits, although not all insurers require it under these circumstances.

Why: "Preventive medicine codes are not global codes," states the American Academy of Pediatrics' (AAP) Coding for Pediatrics. You should separately code developmental screening tests.

Alert: Pay attention to the above combination encounter coding. You will frequently bill developmental testing with a preventive medicine service. The AAP recommends that physicians routinely administer developmental tests during well checks to make sure the child is developing normally, Berland says.

3. Stick With 1 Code for Stand-Alone Testing

Due to time constraints, your pediatrician may separately perform the E/M service (office visit or preventive medicine service) and developmental testing. In this case, submit only the code for the encounter the physician performed.

Illustration: A grandmother presents with her 4-month-old granddaughter for a scheduled DDST-II. Because the infant was born prematurely, the pediatrician routinely performs these screenings.
Report the developmental testing (96110) linked to the appropriate prematurity diagnosis (such as 765.26,

Disorders relating to short gestation and low birthweight; 31-32 completed weeks of gestation). The pediatrician uses the DDST-II as part of neonatal high-risk follow-up.