Primary Care Coding Alert

Guidelines:

Understand How to Code Developmental/Behavioral Screens and Tests

Published on Wed Mar 16, 2022

Do you know which instruments match the codes?

The four codes that comprise the Developmental/Behavioral Screening and Testing section of CPT^®are fairly simple to use. But if you are at all confused by them, all you have to do is remember a few basic differences to apply them correctly.

We’ve broken them down for you here and provided some additional information, including some of the instruments connected to the relevant codes, for you to refer to the next time your provider screens or tests a patient for developmental, emotional, or behavioral concerns.

Understand the Difference Between Developmental and Behavioral/Emotional Screens

“Developmental screenings really look at a patient’s overall development and will include questions on motor skills, language skills, cognitive function, and possibly questions on social, emotional, and behavioral issues. An emotional or behavioral assessment instrument will look specifically at behavior and emotional health related to key symptoms of behavioral or emotional conditions, such as ADHD [attention deficit hyperactivity disorder], depression, or anxiety,” notes Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia.

This means you will apply 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument) for behavioral and emotional screens as the descriptor tells you.

Instruments associated with 96127: The Patient Health Questionnaire-9, Edinburgh Postnatal Depression Scale (administered for the benefit of the mother), and National Institute for Children’s Health Quality (NICHQ) Vanderbilt Assessment Scales are among the tools your provider can administer that you can code using 96127, according to the American Academy of Family Physicians (AAFP) (www.aafp.org/fpm/2017/1100/fpm20171100p25.pdf).

Understand the Difference Between Developmental Screens and Tests

If your provider administers developmental tests to your younger patients, code choice can be a little harder.

The fundamental difference between 96110 (Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument) and 96112 (Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour) lies in the distinction between a screen and a test.

Confusingly, a screen as described by 96110 involves administering, scoring, and documenting a standardized instrument, while a test as described by 96112 involves provider observation and evaluation. A test may or may not involve the use of a standardized instrument, hence the words “when performed” in the descriptor. In other words, “a developmental test requires both objective scoring and subjective observations. When objective measures/scoring are performed only using a standardized instrument, that is a developmental screen,” according to the American Academy of Pediatrics (AAP) (www.aappublications.org/news/2019/04/03/coding040319).

The distinction also explains why test code 96112 is a time-based code as, in addition to representing time spent on test administration, 96112 also includes the interpretation and report preparation your provider performs.

Don’t forget: You can report any time over the first hour of the service using the add-on code +96113 (… each additional 30 minutes…). You’ll determine the exact amount of time to report by following standard CPT^®time definitions “(ie, a minimum of 16 minutes for 30 minutes codes and 31 minutes for 1-hour codes must be provided to report any per hour code),” according to CPT^®guidelines.

Instruments associated with 96110: The Ages & Stages Questionnaires, Parents’ Evaluation of Developmental Status, and Modified Checklist for Autism in Toddlers are among the instruments appropriately reported using 96110, according to AAFP.

Understand Who Can Administer the Instruments

Standardized tools such as the ones listed above for codes 96127 and 96110 are typically administered by clinical staff rather than a qualified healthcare professional (QHP), which is why neither of those codes is assigned physician work relative value units (RVUs) under the resource-based relative value scale used by Medicare and other payers. However, due to the work involved in interpreting and reporting the results of any instruments administered during 96112, a physician or other QHP typically administers and scores the test(s), and the code has work RVUs assigned to it as a result.

Understand How Many Times You Can Report the Codes

According to Medicare’s current Medically Unlikely Edits (MUE) table, you can report up to two units of 96127 per date of service, while MUEs for 96110 are currently fixed at three. Medicare does not specify how many units you can report per year. Depending on payer preference, you might bill per unit or add modifier 59 (Distinct procedural service) to successive codes.

Understand How the Codes Bundle With E/Ms

“All screening and testing services can be billed with any E/M [evaluation and management] service, whether it be a preventive or a sick visit E/M under appropriate circumstances,” advises Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. You can do this by appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M.

Remember: If you do report an office/outpatient E/M with 96112/+96113, make sure you do not count the time and effort in conducting, interpreting, and documenting the test toward the medical decision making (MDM) or time in your E/M selection.