Pediatric Coding Alert

Answer: Unfortunately, most payers do not publish official guidelines that indicate how long you must retain the hard copy of the MCHAT form, and CPT® has never published anything to that effect. Most practices do retain the hard copy forms that the patients and their families filled out, and those that have switched to EHR systems also frequently retain the completed questionnaire. That said, this isn’t necessarily a must, although the documentation of the scoring and physician interpretation and discussion are important to have in the chart.

 

Keep in mind: Code 96110 (Developmental screening, with interpretation and report, per standardized instrument form) 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.”

 

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.