Wiki Help clarifying description cpt 96110

[Lora Cimino]

I do the coding and charge entry for a large family practice. Our pediatrician uses a development screening questionaire called MCHAT and was advised to use code 96110 to report this. In the description it says an interpretation and report is involved. Does scanning the questionaire into EMR and noting in office notes the outcome qualify as such?

Thank you
Lora Cimino CPC

 

[sbicknell]

The forms I am most familiar with included a physician findings and interp section on the last page of a multi-page format. He must complete, sign and date this section of the form. And yes, you scan the form into the EMR.

I also always encouraged the physician to document what month was administered and an interp statement in his note just as he would document the findings/interp of any other diagnostic he performed.