Pediatric Coding Alert

Question: Can you clarify what documentation needs to appear in the medical record when we perform 96110? I am under the impression that the "report" needs to appear in the medical record in order for us to bill it. Does the entire questionnaire or just the summary need to be in the medical record?

Colorado Subscriber

Answer: To support 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report), the medical record should show that a standardized tool was used, interpreted, and scored. The report is the score or designation as "normal" or "abnormal" in the chart. The physician must indicate that he reviewed and discussed the screening's results with the patient or family member.

The actual questionnaire does not need to be included. The test used, however, should be referred to by name so that an auditor can substantiate that a qualifying test was used.

Tool: A sufficient note from the doctor could state, "Developmental screening [Insert: Test Name] [Indicate:Normal or abnormal] reviewed and discussed."