Pediatric Coding Alert

Question: During the history portion of a patient’s evaluation and management (E/M) service, the physician collected information about the child’s development. Can I report the screening separately?

California Subscriber

Answer: If your physician collects information about the child’s development as part of a history during a well visit (or sick-patient encounter) E/M service, this is regarded as surveillance and “not formal ‘screening’ as such, and is not separately reportable” according to the American Academy of Pediatrics (AAP) (https://downloads.aap.org/AAP/PDF/coding_factsheet_developmental­screeningtestingandEmotionalBehvioraassessment.pdf).

Remember: Your physician must use a standardized instrument in order for you to report a formal screening such as the one represented by 96110 (Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument). Examples of such tools include the Ages and Stages Questionnaire (ASQ), the Pediatric Evaluation of Developmental Status (PEDS), or the Modified Checklist for Autism in Toddlers (M-CHAT).

For a comprehensive list of standardized screening tools, go to the AAP’s Screening Time website at www.aap.org/en/patient-care/screening-technical-assistance-and-resource-center/. You can filter the list by such categories as early childhood development, development, autism, and adolescent depression.