Developmental/Behavioral Screening Coding Fact Sheet for Primary Care Providers
Developmental screenings are often complemented by the use of special tests. This Coding Fact Sheet provides guidance on how primary care providers can appropriately report a developmental/behavioral screening using standardized, validated, evidence based screening tools when performed at the same time as a child health exam. Examples of validated tools include, but are not limited to:
· PEDS (Parents’ Evaluation of Developmental Status)*
· ASQ (Ages and Stages Questionnaire)
· ASQ:SE (Ages and Stages Questionnaire: Social-Emotional)
· CSBS DP (Communication and Symbolic Scales Developmental
· M-CHAT (Modified Checklist for Autism in Toddlers)
When billing the developmental behavioral screening, the 96110 code should be used.
Code 96110 (developmental testing; limited) is often reported when performed in the context of preventive medicine services, but may also be reported when screening is performed with other evaluation and management (E&M) services such as acute illness or follow-up visits.
Each administered developmental screening and testing instrument may be primarily completed by a parent. The scoring/results is often part of the screening tool, but elements may alternatively be documented in the progress report of the visit. Physicians must document any interventions based on findings generated by the test and sign off on the documented screening tool.
Note: Asking age appropriate surveillance questions regarding developmental and behavioral concerns is part of the requirements for a complete child health exam for all ages; therefore, the asking of surveillance questions should not be separately reported (billed). More information regarding developmental screening/testing can be found on the American Academy of Pediatrics website.
*Not a screening tool that has either been provided by the screening initiative or is no longer available.