Required documentation for developmental screening 96110/96127

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North Reading, MA
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I would like to know if a provider is required to scan in (the patients chart) the actual screening tool (PHQ-9, M-CHAT, PEDS) when coding a 96110 or 96127. As I am interpreting it they are only required to document the results. Does anyone have any insight on this?

Thanks
 

Kimonae

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Screening 96110/96127

In our office, our providers document and also scan the test(s) into the patient's EHR. The scanning is preferred but not a requirement. It helps to have the imaging just in case the wrong screening was billed. I have seen this happen before.

Carine Kimon, CPC
 
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