Pediatric Coding Alert

Hint: Use modifier -25 to unlock E/M-96110 reimbursement Stop bundling developmental testing into your E/M code when your pediatrician performs the service during well-check encounters. Instead, report CPT 96110 and watch your reimbursement possibly increase by about $100.

A routine check, a concern, or a prior condition may trigger your pediatrician to test a child's development. The following examples show you how to boost your reimbursement with appropriate E/M service and developmental screening codes. 1. Pediatrician Discovers a Problem at a Sick Visit If your pediatrician performs developmental screening during an office visit, you should report both services.

Scenario: A parent presents with her 2-year-old child for suspected delayed language development. The pediatrician performs a history, evaluation and medical decision-making in which he determines that 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 representative to the AMA CPT Advisory Committee.

You should also report the problem-related visit. Use the appropriate-level E/M code, such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an 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). The modifier tells the payer that the office visit is a separately identifiable service from the screening.

Good news: You should collect payment for both your E/M service and 96110 because carriers typically cover both services.

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 (www.affiliate.easterseals.com/site/DocServer/BillingFAQs.doc?docID=2761).

Payment, however, is inconsistent. "Insurers in Missouri typically don't cover 96110," Berland says.
Don't assume that noncoverage equals nonpayment. If a service is noncovered, the patient can be balance-billed. If the insurer considers it bundled or included in the E/M code, then you cannot balance-bill it. 2. Physician Screens During Routine Physical Does your pediatrician 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 pediatrician performs an age-appropriate re-evaluation and management and also uses the Parents' Evaluation [...]