Pediatric Coding Alert

Question: Insurers deny 96110 and/or 96110-59 when we bill both at an 18-month-old visit. What might be the problem?

Maryland Subscriber

Answer: You're correct in reporting 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) for ageappropriate, standardized developmental screenings (such as Ages and Stages) with and an autism screen (MCHAT). The problem might lie with screening limits. Check your payer contracts to verify any limits on the number of screenings you can perform during a single visit or over a certain period of time.

Example: Aetna policies often pay only one unit when you bill two. Aetna also allows only five screenings in the first 36 months of life. If you start screenings before the payer expects, you could run out of reimbursable visits before the child reaches 36 months.

Modifier: You'll also submit the appropriate E/M code for the associated well visit (choose 99382 for a new patient or 99392 for an established patient). Some payers might require modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code. Report 96110 on two separate lines because the physician completed two separate screenings. Append modifier 59 (Distinct procedural service) to the second instance of 96110. Link the appropriate screening diagnosis to justify 96110.

Payers typically cover developmental screenings when linked to the V20.2 (Routine infant or child health check) well infant/ child diagnosis. However, you might also need V79.3 (Special screening for mental disorders and developmental handicaps; developmental handicaps in early childhood) in this instance to support 96110.

Final codes: Your completed claim should include 99610 for the first screening procedure; 96110 with modifier 59 for the second screening procedure; and 99382 or 99392 with modifier 59 for the E/M service. Link a well diagnosis to the procedure codes.