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PEDS:Billing, Coding, and Reimbursement
Can FQHC’s get reimbursed for developmental screening by using the 96110 code?
In some States and for some types of practices (e.g., Federally Qualified Healthcare Centers), clinics are paid a rate “per medical encounter”. When developmental screening is provided, a specified “visit code” (typically a pre-defined preventive service code) is used to trigger enhanced reimbursement. The 96110 screening code is not reimbursed separately even when States have a specified list of tools required for Early Periodic Screening, Diagnosis and Treatment (EPSDT) visits. In such clinics, adoption of quality screens is best evaluated in terms of time saved plus reductions in practice expenses. Consider these self-evaluation questions, especially in light of the advantages afforded by online screening services: · How much time do clinicians spend eliciting informal milestones such as those on age-specific encounter forms? (Published research on this topic does not yet exist but informal time/motion studies suggest that providers spend ~ 1 – 2 minutes on these activities—time that could be saved if parents complete quality skills-focused tools on their own. Accurate parent-report tools are also known to vastly improve detection rates). · How much time is spent eliciting parents’ concerns with informal questions? What percent of visits incur "oh by the way" concerns and how much time is required to address these? (Research shows that informal questions do not work well and result in "door knob" concerns in about 20% of visits. In contrast, accurate measures eliciting parents’ concerns, preferably by self-report in advance of the visit, shave about 3 minutes from average visit length and make encounters far more relevant. Also families are more likely to return for subsequent visits when their specific concerns are elicited and addressed. · If using quality tools in print how much time is spent hand-scoring or administering screens by interview? Would shorter screens with online scoring save time? · How much time is spent dictating/proofing referral letters and parent summary reports? (Published research on this issue does not yet exist but we can anticipate that for about 20% of patients, referrals and thus report dictation/proofing will be needed. These activities require at least 5 – 10 minutes of professional time. To this expense must be added requisite staff time for transcribing dictations). Would not much of this time/expense be eliminated if using an online screening service that automatically generates reports? Informal measures, whether focused on parents’ concerns or children’s milestones incur costs to practices; but these approaches are, unfortunately, without much benefit to patients. Quality screening tools are not without costs but these expenses are minimal and the benefits to children parents and society are enormous. Practice time/expense is minimal if parents self-administer measures. Practice time/expense is reduced further when using online screening services wherein scoring is automated and referral letters and parent summary reports are automatically generated.
How do I bill and code for PEDS and/or PEDS:DM? How can I get reimbursed for screening?

You may need to use the following:

1. Attach the - 25 modifier to your preventive service code or E/M service code (to denote the office visit is a separate service from the screening.Then list 96110 times the number of screens given, (e.g., X 3 if using PEDS+PEDS:DM+MCHAT). [Note that some States (e.g., North Carolina) does not allow an unbundled 96110 but has increased reimbursement substantially for the entire well-visit]. If billing a private payer, particularly Cigna, the -59 modifer is usually required instead of -25

2. Multiple units, with the modifier appended to the visit as described above, best describe the separate entity of performing multiple 96110s. For insurers not accepting units, the distinct procedural service of each test is best represented with - 59 modifier appended to each additional unit of 96110:
Example: A level 3 office visit in which three developmental screening instruments were administered, scored and interpreted:

Appeal all denied claims--sometimes State Medicaid Directors aren't
aware of the federal ruling from 2005, in which the Centers for
Medicare and Medicaid Services published a total relative value unit
(RVU) of 0.36 for 96110, which amounts to a Medicare payment of
about $10.00. For Cigna and many other private payers, reimbursement is about $20.00. This RVU represents only malpractice expense and office expense --no physician work is included--meaning that screening is largely a staff function except for explaining results to families.

None of this can guarantee that a valid claim will be
accepted, so the American Academy of Pediatrics (AAP) is willing to
help with denied claims via their Coding Hotline: 800-433-9016,
ext. 4022, or at

96110 or 96111 procedure codes rarely cover the Denver because it is not validated.

How do I code a screen when the result is normal and will I get reimbursed?

This answer is provided from Linda Walsh at the AAP's Office of Coding and Reimbursement and Dr. Lynn Wegner, Chair AAP Section on Developmental and Behavioral Screening): There are two levels of coding: optimal coding and acceptable coding. While optimal coding would indicate that you link the V79.3 or V20.2 code to 96110 in a patient that screens as "normal," payors do vary on their tendency to (financially) recognize such reporting. A coding purist would tell you to continue to report that code combination and fight it at the contractual level. That's a viable long term solution (and one that should be taken into account when your contract next comes up for renewal) but it doesn't work well in the short term (ie, mid-contract). Therefore, if you find that your payors are not recognizing that code combination, we suggest that you engage an acceptable coding alternative, such as seeing if a code in Chapter 16 of ICD-9-CM (Symptoms, Signs, and Ill-Defined Conditions) is a reasonable alternative. So, Developmental screening ICD-9 codes are all v codes, unfortunately. For example, Screening for: developmental handicap V79.9 (Screen developmental problems V79.c)in early childhood V 79.3 Now, if you had documented in the chart any reported delays (despite normal results after the screening), you could use: 783.42 Delayed Milestones 315.8 Other specific Delays in Dev 315.9 Unspecified Delays in Dev AFTER, the screening (ie next visit) you could NOT use these three codes as you would have screened 'normal'.

How do I code for the PEDS: Developmental Milestones-Assessment Level (PEDS:DM-AL)?
Use 96111: Developmental testing, (includes assessment of motor language, social, adaptive, and/or cognitive functioning by standardized developmental instruments with interpretation and report). This code includes ~ 3.83 RVUs for provider time (for administration, scoring, explaining results to families, and report writing) which calculated (in 2005) to a Medicare payment of $145.15 [3.83 x $37.8975 (Medicare 2005 conversion factor) = $145.15].The RVU’s are based on 1 hour of provider time. 96111 can be used along side an E/M code on the same date by appending with -25 or -59. If following a child with special health care needs (e.g., an NICU graduate) use any of the following E/M codes: 99211–99215 Consider the following ICD-9 diagnosis codes (until October, 2104 when the ICD-10 will replace the ICD-9. We will update this page at that time). These codes are general in nature so as not to interfere with more refined diagnoses available when children are older and can be administered very detailed measures. 783.4 Developmental Delay 309.23 Academic Inhibition (school problems) 315.4 Developmental Coordination Disorder 784.5 Other Speech Disturbance 309.3 Disturbance of Conduct 765.18 Other preterm infant For a helpful crosswalk between the ICD-9 and ICD-10 see:
What are the best diagnosis codes to use for ICD-10
F98.9 Unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence F82 Specific developmental disorder of motor function F80.89 Other developmental disorders of speech or language F90.9 Attention Deficit Hyperactivity Disorder, unspecified type F79 Unspecified intellectual disabilities F81.9 Developmental disorder of scholastic skills, unspecified
What are the best diagnosis codes to use for problematic PEDS/PEDS:DM results?

Commonly used ICD-9 codes are those sufficiently vague as to not interfere with a more complete diagnoses made by those to whom you refer:

Commonly Used Diagnosis Codes in response to screening test results include:
783.4 - Developmental Delay
309.23 - Academic Inhibition (school problems)
315.4 - Developmental Coordination Disorder
784.5 - Other Speech Disturbance
309.3 - Disturbance of Conduct