FAQ
Billing, Coding and Reimbursement
- 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?
How do I code a screen when the result is normal and will I get reimbursed?
What are the best diagnosis codes to use for ICD-10?
Code | Description
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
- 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) do not allow an unbundled 96110 but have increased reimbursement substantially for the entire well-visit]. If billing a private payer, particularly Cigna, the -59 modifer is usually required instead of -25.
- 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:
- 99213
- 96110
- 96110-59
- 96110-59
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 aapcodinghotline@aap.org
96110 or 96111 procedure codes rarely cover the Denver because it is not validated.
How do I code for the PEDS®: Developmental Milestones-Assessment Level (PEDS:DM-AL®)?
Beginning in 2019, developmental testing codes 96112 and 96113 should be used for developmental testing including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed. These codes cover administration by physician or other qualified health care professional, with interpretation of results and creating a report.
Use 96112 for the first hour of testing (> 31 minutes). (wRVU 2.56).
Use 96113 for representing each additional 30-minute increment required to complete the service (list separately in addition to code for primary procedure). Note that the mid-point rule requires 76 minutes to pass before adding the first 96113. (wRVU 1.16)
This new coding structure enables physicians or other qualified health care professionals to report these services based on total time. This is a change from the previous 96111 code which limited you to reporting a single unit of code, regardless of time spent providing the service. These new reporting codes cover multiple days of review and interpretation of data.
Time Spent Developmental Testing Code(s)
< 31 mins N/A (report an E/M service if appropriate)
31-76 mins (1 hr and 16 mins) 96112
77-106 mins (1 hr and 46 mins) 96112 and 96113
107 mins –136 mins (2 hr and 16 mins) 96112 and 96113 x 2 units
137 mins –166mins (2hr and 46 mins) 96112 and 96113 x 3 units
These ICD-10 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.
Code | Description
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 Diagnosis Codes in response to screening test results include:
Code | Description
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