Primary Care Coding Alert

If your family physician (FP) performs developmental testing during well-check encounters, don't bundle the testing into your E/M code. Instead,  report 96110 and watch your reimbursement possibly increase by about $100.

A concern, a routine check or a prior condition may trigger your FP to test a child's development. The following examples show you how to boost our reimbursement with appropriate E/M service and developmental screening codes.

If your FP performs developmental screening with an office visit, you should report both services.

Scenario: A parent presents with her 9-month-old infant for suspected delayed language development. The FP performs a history, evaluation and medical decisionmaking in which he determines the infant requires developmental testing. He questions the mother about the infant's responses and behaviors using the Denver Developmental Screening Test II (DDST-II).

You should submit 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with  interpretation and report) for limited developmental testing. "Code 96110 includes interpreting and reporting a multitude of tests, such as the DDST-II or the Early Language Milestone Screen," says David I. Berland, MD, American Academy of Child and Adolescent Psychiatry (AACAP) representative to the AMA CPT Advisory Committee.

You should also report the problem-related visit. Use the appropriate-level E/M code, such as 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient ...), appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says LeeAnn Shumiloff, billing manager at West Virginia University Health Sciences Center in Morgantown. The modifier tells the payer that the office visit is a separately identifiable service from the screening.

Good news: You might collect payment for both your E/M service and 96110 ($13.82). "Carriers typically cover both services," Shumiloff says.

Even though Medicare pays 96110 at $13.82 (geographically unadjusted rate for 0.37 relative value units), some carriers pay much more. For those payers that cover developmental testing, "reimbursement is typically around $100 or more," says Ellen Harrington-Kane, MS, HSM, OTR/L, medical rehabilitation services senior director at Easter Seals in Chicago in Billing FAQs. To download this Word document from www.google.com, enter "Easter Seals + Billing FAQs" in the search engine and click on "Send Your Questions for Ellen Harrington- Kane, Senior Director of ..."

Payment, however, is inconsistent. "Insurers in Missouri typically don't cover 96110," Berland says.

Don't assume that noncoverage equals nonpayment. "If an insurer denies 96110, bill the patient, provided your contract permits it," Berland says.

Does your FP perform routine developmental screenings at well visits? Take this opportunity to bill both services.

Example: A father presents with his 4-year-old son for the child's annual physical. The FP performs an ageappropriate re-evaluation and management and also uses the Parents' Evaluation of Developmental Status (PEDS) to measure the child's developmental progress.

In this case, you should report the age-specific preventive medicine service and the developmental testing. Submit 99392-25 (Periodic comprehensive preventive medicine reevaluation and management of an individual ...; early childhood [age 1 though 4 years]) and 96110.

Why: "Preventive medicine codes are not global codes," states the American Academy of Pediatrics' (AAP)  Coding for Pediatrics. You should  separately code developmental screening tests.

Alert: Pay attention to the above combination encounter coding. You will frequently bill developmental testing with a preventive medicine service. The AAP recommends that physicians routinely administer developmental tests at well checks to make sure the child is developing normally, Berland says.

Due to time constraints, your FP may separately perform the E/M service (office visit or preventive medicine service) and developmental testing. In this case, submit only the performed encounter code.

Illustration: Suppose a grandmother presents with her 4-month-old granddaughter for a scheduled DDST-II. Because the infant was born prematurely, the FP routinely performs these screenings.

Report the developmental testing (96110) linked to the appropriate prematurity diagnosis (such as 765.26, Disorders relating to short gestation and low birthweight; 31-32 completed weeks of gestation). "The FP uses the DDST-II as part of neonatal high-risk follow-up," Shumiloff says.