Pediatric Coding Alert

Question: At a 24-month established patient preventive medicine service, a mother describes her child as "crazed," completes the Parent Evaluation of Developmental Status (PEDS), and responds positively to the question "Do you have concerns about your child's language skills?" The nurse scores the PEDS and places the answer sheet on the front of the chart with a red arrow sticker next to it.
 
When the pediatrician examines the child, the sticker alerts him to ask the mother about her observations of the child's language ability. The physician then confirms the delay in language and refers the patient to a local speech pathologist. Should I report the developmental assessment?

Illinois Subscriber

Answer: Yes. Because the pediatrician used a standardized developmental screening instrument (in this case, the PEDS), report the limited developmental testing with CPT 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report).
 
"When physicians ask questions about development as part of the general informal developmental survey or history, this is not a 'test' as such, and is not separately reportable," says the American Academy of Pediatrics Developmental Screening/Testing Coding Fact Sheet for Primary-Care Pediatricians.
 
Regardless of the type of E/M service that the pediatrician performs, you should report the limited screening test along with the E/M service. Although physicians often perform 96110 in the context of a preventive medicine service, you may encounter scenarios in which testing is performed with other E/M services, such as acute illness or follow-up office visits, such as Vanderbilt forms for ADD/ADHD Evaluations and Follow-Up.
 
Append the preventive medicine service (99381-99397) or the office visit (99201-99215) with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). The modifier indicates that the E/M service was distinct and necessary at the same visit.
 
Because the case you describe involves limited screening testing at the time of a 24-month established patient preventive medicine service, you should report as shown in chart.

Don't overlook: If the pediatrician spent significant extra time evaluating the language problem, you may report an office visit in addition to the preventive medicine service. Link 99212-99215 appended with modifier 25 to the appropriate ICD-9 code(s), such as 315.31, 315.32 (Mixed receptive-expressive language disorder), or 315.39 (Other developmental speech or language disorder).