Pediatric Coding Alert

Not screening your major payers' developmental testing policies can leave the patient -- or your practice -- stuck with the bill.

Suppose an office uses the DDST at annual well exams and bills 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) for completing the questionnaire and documenting the results. A common question pops up: "Until what age can this be done?" asks Kausar S. Kherani, MD, in Westlake, Ohio.

The answer hinges on the guideline you're following. Here's how to maximize your pay.

"Even though 96110 has no age limit," carriers may impose restrictions, says Patti DiSpazio, CPC, business manager at Island Coast Pediatrics in Fort Myers, Fla. Some plans may limit the code at age 11, others at age 17.

Strategy: You've got to research your major payers' policies. Reimbursement guidelines vary by plan, including arbitrary age limits, allowed frequency, covered diagnoses, and noncoverage.

Any age limits that plans include are arbitrary and not based on CPT coding guidelines, says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

96110's descriptor does not specify an age. In addition, the "Central Nervous System Assessments/Tests (e.g., Neuro-Cognitive, Mental Status, Speech Testing)" notes contain no age reference for the codes in the section.

Developmental screening can occur at any preventive medicine service (99381- 99385 for "Preventive Medicine Services, New Patient" or 99391-99395 for "Preventive Medicine Services, Established Patient") or a problem-oriented visit (99201-99215, "Office or Other Outpatient Services"). "The frequency of reporting 96110 is dependent on the clinical situation," according to the American Academy of Pediatrics' (AAP) "Developmental Screening/Testing Coding Fact Sheet for Primary Care Pediatricians".

The AAP's Bright Futures "Recommendations for Pediatric Health Care" suggests that developmental screening occur at the 9-, 18-, and 30-month preventive medicine services. The evidence-based guidelines recommend autism screening at the 18- and 24-month preventive medicine services. Associated codes include:

• 99381 -- Initial comprehensive preventive medicine evaluation and management of an individual ... new patient; infant (age younger than 1 year)

• 99382 --...early childhood (age 1 through 4 years)

• 99391 -- Periodic comprehensive preventive medicine reevaluation and management of an individual ... established patient; infant (age younger than 1 year)

• 99392 --...early childhood (age 1 through 4 years).

Although you might associate 96110 with a younger group, the test used can make the code apply to an older group. The Vanderbilt "can work for younger or older children because it is basically collecting DSM-IV-based information about attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and compulsive disorder (CD), and the same diagnostic criteria are used for all three age groups," explains the test's creator, Mark L.Wolraich, MD, professor of pediatrics at Children's Medical Research Institute/ShaunWalters at OU Child Study Center in Oklahoma City. It was initially tested on children 5-12 years, but there is "also good evidence that the criteria hold up for 4- to 6-year-olds," he says.

The DDST applies to a younger group. "The DDST is a norm-referenced screening tool designed to be a quick assessment to identify children from 1 month to 6 years of age with developmental delay," according to Edward Taub's "Case Report," published in Physical Therapy Nov. 1, 2003.

Warning: Report 96110 only when the service uses a validated standardized tool, not a homegrown set of questions. The AAP "Developmental Surveillance and Screening of Infants and Young Children" policy  statement recommends that physicians use validated developmental screening tools to improve detection of problems at the earliest possible age to allow further developmental assessment and appropriate early intervention services. For a listing of accepted tools, check out the AAP's 96110 Fact Sheet available at www.gaaap.org/HCS&Surveillance.htm.