Pediatric Coding Alert

Question: Our office has the parent complete the MCHAT, which we then scan into the patient’s documentation. The paediatrician will indicate that he reviewed the MCHAT with the patient and the parent, and note that in the documentation as well.  Is scanning the MCHAT into the patient’s documents enough if an insurance company ever does an audit of the patient’s records?

Kentucky Subscriber

Answer: Code 96110 is for developmental testing, limited, “with interpretation and report” (I&R). The interpretation has to follow a formal assessment like a Denver sheet. The interpretation is the assessment, so your scanned sheet will most likely suffice for that. The report is the documentation, such as the score or designation as “normal” or “abnormal,” in the chart. You do not have to be sending the report to someone else. The physician, however, must indicate that he reviewed and discussed the screening’s results with the patient/ family member. A sufficient note from the doctor could state, “Developmental screening [Indicate: Normal or abnormal], reviewed and discussed.”

Bright Futures guidelines, which set the gold standard on preventive medicine on pediatric care, recommend MCHATs (which are standardized screening tools for autism) at 18 months and either 24 or 30 months.

If all of that is documented on the MCHAT sheet that the patient’s parent completed, you should be fine if you’re ever audited. Auditors don’t require that your documentation is on a specific type of form, they just want it to be there. If your physician filled out his interpretation and report of the MCHAT directly on the sheet that the parent completed, then the documentation should be sufficient.