Pediatric Coding Alert

Don’t forget to heed AAP’s advice and guidance.

Age-appropriate screens or tests that assess a patient’s developmental, emotional, or behavioral status are key components of pediatric care. So, it’s important that you know what they are, how they should be administered, and the correct way to code them.

Here, then, are four great tips to help you avoid common screening and testing coding pitfalls in the future.

Tip 1: Know the Difference Between Developmental and Behavioral/Emotional Screens

Choosing the right code for a screen begins with an understanding of what the screens are actually assessing.

“Developmental screenings really look at a patient’s overall development and will include questions on motor skills, language skills, cognitive function, and possibly questions on social, emotional, and behavioral issues,” notes Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia. “An emotional or behavioral assessment instrument will look specifically at behavior and emotional health related to key symptoms of behavioral or emotional conditions, such as ADHD [attention deficit hyperactivity disorder], depression, or anxiety,” Miller adds.

Fortunately, CPT^® code descriptors are pretty clear in distinguishing between developmental and behavioral screening and assessments, and you should have no problem correctly applying either 96110 (Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument) or 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/ hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument) to the appropriate service.

Remember: If your pediatrician collects information about the child’s development as part of a history during a sick or well evaluation and management (E/M) service, this is regarded as surveillance and “not formal ‘screening’ as such, and is not separately reportable” according to the American Academy of Pediatrics (AAP) (Source: www.aap.org/en-us/Documents/coding_factsheet_developmentalscreeningtestingandEmotionalBehvioraassessment.pdf).

Your pediatrician must use a standardized instrument in order for you to report a formal screening such as the one represented by 96110.

For a comprehensive list of standardized screening tools, go to the AAP’s Screening Time website at screeningtime.org/star-center/#/screening-tools. You can filter the list by such categories as early childhood development, development, autism, and adolescent depression.

Coding alert 1: Typically, clinical staff perform 96110 and 96127 services. This is reflected by the Medicare valuation of the screens, which do not include physician work values.

Tip 2: Know the Difference Between a Screen and a Test

Less obvious when assessing a child’s development is the difference between a screen and a test. So, it’s important to understand that “while both use validated and standardized instruments, screening is more of an observation of the patient’s development, and testing is an actual measurement of development,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

This is similar to AAP’s definitions, which state that “screening asks a child’s observer to provide his/her observations of the child’s skills, which are then recorded on a standardized and validated screening instrument. Screening is subjective and only reports the assessment of the patient’s skills through observation by the informal observer. On the other hand, testing measures what the patient is actually able to do on a standardized psychometric instrument at that time.”

Again, though, the CPT^® code descriptor for developmental testing is clear, and you would use time-based code 96112 (Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour) and its add-on +96113 (… each additional 30 minutes (List separately in addition to code for primary procedure)), when appropriate, when your pediatrician administers the test.

Tip 3: Know How Often You Should Conduct Screens

“The AAP Bright Futures ‘Recommendations for Preventive Pediatric Health Care’ schedule recommends developmental/behavioral surveillance at each health supervision visit, and a formal depression assessment at each annual visit from age 11 on,” Miller advises. These recommendations can be found in the AAP’s most recent periodicity schedule at downloads.aap.org/AAP/PDF/periodicity_schedule.pdf.

Tip 4: Know if You Can Report a Screen/Test and an E/M

“All screening and testing services can be billed with any E/M service, whether it be a preventive or a sick visit E/M, under appropriate circumstances” Falbo advises. Per AAP, you would do this by appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M and modifier 59 (Distinct procedural service) to the screening or test code.

Coding alert 2: AAP cautions against double dipping with 96112/+96113. If you do report an office/outpatient E/M with these codes, make sure you do not count the time and effort in conducting the testing toward the medical decision making (MDM) or time in your E/M selection.