Primary Care 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 FP 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 FP used a standardized developmental screening instrument (the PEDS), you should report the limited developmental testing using 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 the FP 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.

Append the preventive medicine service (e.g., 99392 in this case) or the office visit (99201-99215) code 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:

Don't overlook: If the FP 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). Answers to You Be the Coder and Reader Questions reviewed/provided by Jim Collins, CPC, CHCC, president of Compliant MD Inc.; Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City; Victoria S. Jackson, practice management consultant with JCM Inc. in California; and Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, [...]