Primary Care Coding Alert

Hint: Modifier -25 unlocks your E/M-96110 pay If your family physician (FP) performs developmental testing during well-check encounters, don't bundle the testing into your E/M code. Instead,  report 96110 and watch your reimbursement possibly increase by about $100. A concern, a routine check or a prior condition may trigger your FP to test a child's development. The following examples show you how to boost our reimbursement with appropriate E/M service and developmental screening codes. 1. FP Discovers a Problem at a Sick Visit If your FP performs developmental screening with an office visit, you should report both services.

Scenario: A parent presents with her 9-month-old infant for suspected delayed language development. The FP performs a history, evaluation and medical decisionmaking in which he determines 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 (AACAP) representative to the AMA CPT Advisory Committee. You should also report the problem-related visit. Use the appropriate-level E/M code, such as 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or 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), says LeeAnn Shumiloff, billing manager at West Virginia University Health Sciences Center in Morgantown. The modifier tells the payer that the office visit is a separately identifiable service from the screening.

Good news: You might collect payment for both your E/M service and 96110 ($13.82). "Carriers typically cover both services," Shumiloff says. 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. To download this Word document from www.google.com, enter "Easter Seals + Billing FAQs" in the search engine and click on "Send Your Questions for Ellen Harrington- Kane, Senior Director of ..."

Payment, however, is inconsistent. "Insurers in Missouri typically don't cover 96110," Berland says.

Don't assume that noncoverage equals nonpayment. "If an insurer denies 96110, bill the patient, provided your contract permits it," Berland says. 2. Screening Meets Routine Physical Requirements Does your FP perform routine developmental [...]