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Wiki 96110 - into EMR/LMR

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HBULLOCK

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I was wondering if anyone knew where I could find in writing that the screening sheets need to be scanned into EMR/LMR?? I'm trying to convince management that they need to be scanned as proof they were done, not just the doctor noting it was done. Thanks!
 
On 2/15/2009 the AAP presented a lengthy article on Developmental Screening/Testing called "Developmental Screening/Testing Coding Fact Sheet for Primary Care Pediatricians."

On page 7 of this article it states ...."the item results should be scored and the test protocal and any/all scoring sheets should be included in the medical chart (computer scanning may be needed for electronic medical records). A brief interpretation should be recorded and notation should be made for further evaluation or treatment fo the patient or family."

I know this is a little old, but doubt that this portion of the article (regarding documentation) would have changed.

Some payers require proof of the testing sheets so that is another reason we scan all of ours. If you want a copy of the full article and don't have access to AAP, give me your email and I'll scan and send the article to you. It's helpful.
 
Looking for feedback on the form used for billing 96110. Is a one page chart called "WELL CHILD CARE CHECK SHEET" with five columns and the doc puts a check mark in one of the boxes?

Here are the five columns:
Age
Developmental tasks (lists social, fine motor, language, gross motor)
check boxes to indicate which percentile the child accomplishes (here is where the doc puts a check)
Anticipatory guidance (safety, feeding, feeling, symptomatic with a "check if discussed" note (that is never checked!)
Procedures (Hgt, Wgt, HC, PKU, UA - circle if done - never circled!)

So, my question is, does ONE check on this form sufficiently document 96110?

Thanks in advance for your assistance!
 
In order to report code 96110, a standardized instrument must be used. This would be a screening instrument that has been validated to have sensitivity and specificity necessary to detect developmental delay (eg, Ages and Stages, MCHAT). The forms are typically completed by a parent or other caregiver and then interpreted by the physician (with written interpretation documented). This is different from the developmental surveillance that may be noted in checklists at each well-child visit, do not involve use of a standardized instrument, and are not separately reported.
 
Thanks, Cynthia. Where did you gather this information? In particular, I'm looking to be able to education the physician that 'written interpretation' means there has to be SOMETHING other than a check in one of the boxes.
 
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