Pediatric Coding Alert

Although CMS originally withheld RVUs for this code, you'll now find an update.

If your Medicaid provider is sending back your developmental screening claims and marking them "denied," there's a powerful new tool that can help you fight those zero-reimbursement situations.

Issue Lies in Testing vs. Screening Difference

Although most annual CPT® updates have the potential to help your practice substantially, others can threaten to bring your income to a halt. Unfortunately, that's been the case for scores of pediatric practices that have been stymied by the recent adjustment to the developmental screening code 96110 (Developmental screening, with interpretation and report, per standardized instrument form).

Because this code was previously referred to as a developmental "testing" code, reimbursement was never an issue for it. However, since many Medicaid payers don't pay for "screening," some practices had to fight their payers for hours over the denial of these services. To quell this issue, CMS released an "Informational Bulletin" on Dec. 28 that advises how to collect for these services.

"Many State Medicaid agencies have developed fee schedules based upon Medicare billing codes and associated relative value units," the bulletin states. "As Medicare does not pay for screening or preventive services...CMS modified the active status of code 96110 and did not include associated value units in the 2012 Medicare Resource Based Relative Value Scale physician fee schedule (PFS)."

"This change resulted in many questions and potentially unintended consequences for other payers," CMS said. "We want to be clear that Medicaid and other private payers will be able to continue to use code 96110 even though it is a statutorily non-covered service under Medicare. In addition, many State Medicaid programs rely upon Medicare-published relative value units, including those associated with code 96110."

Because of this confusion, CMS announced that Medicare will update its 2012 Fee Schedule to denote the 2012 payment rate for 96110, which is 0.28 RVUs. The code will be noted status "N," indicating that 96110 is a non-covered service for Medicare payers. It should be recognized and covered by other payers, including Medicaid.

Use CMS Letter as Your Appeal Tool

If your Medicaid or private payer is following the original 2012 CMS directive to assign zero RVUs to 96110, you'll want to appeal any denials based on that erroneous value assignment.

In addition to your appeal letter, you should include a copy of CMS's clarification, which clearly states the new RVUs for 96110. You can print a copy of the letter at www.medicaid.gov/Federal-Policy-Guidance/downloads/FY-2011-CHIPRA-Performance-Bonuses.pdf, or get one by emailing editor Torrey Kim (torreyk@codinginstitute.com).