Developmental Reporting

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Coding for Standardized Assessment, Screening and Testing

Developmental

CODING

Developmental screening is conducted using age-appropriate instruments, which vary in length. This coding

fact sheet provides guidance on how pediatricians can appropriately report those instruments which are

considered to be standardized* developmental screening and testing services. Surveillance and non-

standardized instruments are not separately reported from the evaluation and management service (eg,

preventive medicine service).

*Standardized Instruments: Used in the performance of these services. Standardized instruments are validated

tests that are administered and scored in a consistent or “standard” manner consistent with their validation.

For further guidance on the performance of developmental screening and surveillance, please reference the

AAP clinical report titled “Promoting Optimal Development: Identifying Infants and Young Children with

Developmental Disorders through Developmental Surveillance and Screening” and the Screening Technical

Assistance & Resource (STAR) Center.

How To Report Developmental Screening/Testing

Screening

96110 Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and

documentation, per standardized instrument

The use of standardized* developmental screening instruments is reported using Current Procedural Terminology

(CPT

) code 96110 (Developmental screening). Code 96110 is reported when performed in the context of preventive

medicine services. This code also may be reported when screening is performed with other evaluation and

management (E/M) services such as acute illness or follow-up office visits. If multiple standardized* screens are

performed on a patient, report 96110 with 2 units (or on separate line items). Modifier 59 may be required to

indicate that the services are distinct.

The 96110 code descriptor includes the word screening which differentiates it from the word testing that is included

in the descriptor under codes 96112-96113. Screening asks a child’s observer to provide his/her observations of the

child’s skills, which are then recorded on a standardized* and validated screening instrument. Screening is

subjective and only reports the assessment of the patient’s skills through observation by the informal observer. On

the other hand, testing measures what the patient is actually able to do on a standardized* psychometric

instrument at that time. Screening does not imply a diagnosis, only the means by which information is collected

on the patient.

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Because clinical staff typically performs the 96110 services, the Medicare Resource-Based Relative Value Scale

(RBRVS) relative values reflect only the practice expense (clinical staff time, medical supplies, medical

equipment) and professional liability insurance -- there is no physician work value published on the Medicare

physician fee schedule for this code.

On the less common occasion where a physician performs this service, it may still be reported with code 96110,

but only the ordering would count under the data point for MDM. Do not include the time spent administering

the test in the time for the E/M service. When an assessment is performed along with any E/M service (eg,

preventive medicine or office outpatient), both the 96110 and the E/M service should be reported and modifier 25

(significant, separately identifiable evaluation and management service by the same physician on the same day of the

procedure or other service) should be appended to the E/M code to show the E/M service was distinct and necessary.

Testing

96112 Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level,

social, memory and/or executive functions by standardized developmental instruments when performed), by physician or

other qualified health care professional, with interpretation and report; first hour

+96113 each additional 30 minutes (Add-on code, list separately in addition to code 96112)

Developmental testing using standardized* instruments are reported using CPT codes 96112-96113. This service

may be reported independently or in conjunction with another code describing a distinct patient encounter

provided on the same day as the testing (eg, an evaluation and management code for outpatient consultation). A

physician or other trained professional typically performs this testing service. Therefore, there are physician work

RVUs published on the Medicare RBRVS for this code. Please note that you may not report code 96112 for 30

minutes of time or less. This includes testing time and interpretation and report; however, you may only count the

reporting provider’s (eg, physician or psychologist) time.

When 96112/96113 is reported in conjunction with an E/M service, the time and effort to perform the developmental

testing itself should not count toward the time for selecting the accompanying E/M code.

Just as discussed for 96110, if the E/M code is reported with 96112, modifier 25 (significant, separately identifiable

evaluation and management service by the same physician on the same day of the procedure or other service)

should be appended to the E/M code or modifier 59 (distinct procedural service) should be appended to the

developmental testing code, showing that the developmental testing services were separate and necessary at the

same visit.

Time Spent and Reporting

Time Spent

Code(s) Reports

30 minutes or less

Use E/M service

31-75 minutes

96112

76-121 minutes

96112 and 96113

122-167 minutes

96112 and 96113 and 96113

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When To Report Developmental Screening/Testing

96110

The frequency of reporting 96110 (Developmental screening) depends on the clinical situation. The AAP Bright

Futures “Recommendations for Preventive Pediatric Health Care” schedule recommends

developmental/behavioral surveillance at each preventive medicine visit, and the AAP “Promoting Optimal

Development: Identifying Infants and Young Children with Developmental Disorders through Developmental

Surveillance and Screening” clinical report recommends that physicians use validated/standardized*

developmental screening instruments to improve detection of problems at the earliest possible age to allow

further developmental assessment and appropriate early intervention services.

The use of validated/standardized* developmental screening instruments enhances the task of developmental

assessment typically done in the preventive medicine setting. Screening using a validated/standardized*

developmental screening instrument should be routinely conducted at the 9-, 18-, and 30-month visits and

screening for autism spectrum disorder should be conducted at the 18 and 24month visits. However, a

standardized* screening instrument can be administered at any encounter when the physician determines that

the patient requires one. This may be due to the fact that a patient may not have had one at a previous visit, or a

concern is raised. There is no limitation on when to perform if a concern is raised or a problem is suspected.

When physicians ask questions about development as part of the general informal developmental survey or

history (eg, surveillance) or complete checklists, this is not formal "screening" as such and is not separately

reportable. Vignettes are provided below.

96112-96113

Longer, more comprehensive developmental assessments of patients suspected of having problems are typically

reported using CPT code 96112/96113 (Developmental testing). These tests are typically performed by physicians,

psychologists or other trained professionals and require a minimum of 31 minutes of time spent and documented. They

also are accompanied by an interpretation and formal

report, which may be completed at a time other than when the patient is present but is included under the initial 96112-

96113 reporting.

Like code 96110, the frequency of reporting code 96112/96113 is dependent on the needs of the patient and the judgment

of the physician. When developmental surveillance or screening suggests an abnormality in a particular area of

development, more extensive formal objective testing is needed to evaluate the concern. In contrast to adults, the

limited ability of children to maintain focused selective attention and testing speed may mean that several sessions are

needed to evaluate the problem properly. Code 96112 is reported only once per date of service. There must be an

accompanying report describing and interpreting all testing.

Additionally, subsequent periodic formal testing may be needed to monitor the progress of a child whose skills initially

may have not been “significantly low,” but who was clearly at risk for maintaining appropriate acquisition of new skills.

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II.

CLINICAL VIGNETTES

96110 Vignette # 1

At a follow-up visit for bilateral otitis media, the pediatrician notes the patient missed her 12-month well- child

visit. He requests and the child’s father completes a validated/standardized* developmental screening

instrument. The father endorses no concerns in any developmental domain. The pediatrician reviews the father’s

completed instrument and asks him if his daughter is using single words to convey her

wants and uses words to label common objects. The father assures him that she is doing this, and, in fact, other

non-family adults have commented on her clear articulation. No concerns at all are reported, and this is

consistent with what the pediatrician has observed in the office visits. He tells the father they will continue to

monitor for any evidence that the child is not acquiring skills at an expected rate. All this is noted in a few

sentences in the chart note.

*NOTE: Some payers may require alternate reporting wherein the modifier 59 is appended to the

developmental screening code.

96110 Vignette #2

At a 24-month well child check, the mother describes her toddler as "wild,” completes a validated/standardized*

developmental screening instrument, and responds positively to a question about concerns with language skills.

The nurse scores the instrument and places the answer sheet on the front of the chart with a red arrow sticker next

to it. When the pediatrician examines the child, he is alerted to ask the mother about her observations of the

child’s language ability. He then confirms the delay in language and makes a referral to a local speech pathologist.

If the pediatrician spent significant extra time evaluating the language problem, then an E/M service

office/outpatient code from the 99202-99215 series may be reported using a modifier 25, linked to the appropriate

ICD-10-CM code(s) as appropriate (eg, F80.1, Expressive language disorder; F80.2, Mixed receptive-expressive

language disorder; F80.89, Other developmental disorders of speech or language)

CPT

ICD-10-CM

99392-25* Preventive medicine service

established patient, age 1-4

Z00.129 Encounter for routine child health examination

w/o

abnormal findings

96110 Developmental screening

Z13.42 Encounter for screening for global developmental

delays

CPT

ICD-10-CM

99392-25* Preventive medicine service established

patient, age 1-4

Z00.121 Encounter for routine child health examination

w/ abnormal findings

96110 Developmental screening

Z13.42 Encounter for screening for global

developmental delays

F80.1 Expressive language disorder

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96110 Vignette #3

At a five-year health maintenance visit, a father discusses his daughter’s difficulty “getting along with other little

girls.” “Doctor, she wants friends, but she doesn’t know how to make — much less keep — a friend.” Further

questioning indicates the little girl is already reading and writing postcards to relatives but has not learned how

to ride her small bicycle, is awkward when she runs, and she avoids the climbing apparatus at the playground.

Her father wondered if her weaker gross motor skills affected her ability to play successfully with other children.

She seems very happy to sit and look at books about butterflies — her all-consuming interest! The child’s physical

exam consistently fell in the range of ‘normal for age’ in previous health maintenance visits. The pediatrician asks

her nurse to administer a screening tool for autism spectrum disorder and the father’s responses yield an

abnormal score. The pediatrician reviews the form, writes a brief summary, and discusses her observations with

the father. A referral is made to a local physical therapist who has a playground activities group and to a local

psychologist who has expertise in diagnosing autism spectrum disorder.

CPT

ICD-10-CM

99393-25* Preventive medicine service

established patient, age 5-11

Z00.121 Encounter for routine child health examination w/

abnormal findings

96110 Developmental screening

Z00.121 Encounter for routine child health examination w/

abnormal findings

F82 Specific developmental disorder of motor function

F98.9 Unspecified behavioral and emotional disorders with

onset usually occurring in childhood and adolescence

*NOTE: Some payers may require alternate reporting wherein the modifier 59 is appended to the

developmental screening code.

96112/96113 Vignette #1

An eight-year-old boy with impulsive, overly active behavior and previously assessed "average" intelligence is

referred for evaluation of attention deficit disorder. Prior history reading and written expression skills at first-

grade level and received speech and language therapy during his attendance at Head Start at four years old.

Behavior and emotional regulation rating scales completed by the parent and teacher were reviewed at an earlier

evaluation and management service appointment. History, physical and neurological examinations were also

completed at that visit.

On this visit, standardized* testing was administered to confirm auditory and visual attention, short-term and

working memory, as well as verbal and visual organization. Testing was administered for standard scores as well

as structured observations of behavior. These scores and observations were integrated into a formal report to be

used to individualize his education and treatment plan. Testing and the report took 85 minutes. The family

schedules a follow-up visit to discuss this report and the final diagnosis and treatment plan with the physician.

CPT

ICD-10-CM

96112 Developmental testing, first hour

96113 Additional 30 minutes

F90.- Attention-deficit hyperactivity

disorders

4th digit

0 = predominantly inattentive

type

1 = predominantly hyperactive type

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2 = combined type

8 = other type

9 = unspecified type

96112 Vignette #2

A 5 ½- year-old patient just beginning kindergarten was seen for developmental testing. At a previous visit, the

caregiver’s responses on a validated/standardized* developmental screening tool suggested expressive language

delays. After greeting the parent and child and explaining to the child that, along with the doctor, they would do

some ‘non-school’ activities to see how the patient ‘used words to tell others about good ideas,’ the patient and

the examiner spent fifty minutes together completing the tasks for developmental testing. The examiner scored

the two tests in five minutes, and there was a significant discrepancy detected. Both test scores were abnormal,

however, indicating a mixed receptive–expressive language disorder.

CPT

ICD-10-CM

96112 Developmental testing

F80.2 Mixed receptive-expressive language disorder

96112 Vignette #3

A 9-year-old established patient, being treated for ADHD and receiving language therapy to improve weak

receptive and expressive language skills, comes in for a medication visit. Both the mother and teacher feel the

current dosage of her stimulant medication is effective and neither perceives a need for

any changes. The pediatrician’s services meet the “limited” level of complexity for the visit. However, while asking

about school performance, the child’s mother volunteers, that the patient has been seeing the speech

pathologist once a week for 7 months now but can’t see any signs that her vocabulary is increasing.

The pediatrician administers and scores a standardized* developmental test. The performance standard score

had increased by one standard deviation from the initial performance eight months ago. The pediatrician shows

the child’s mother the improvement and documents the test administration, results, and interpretation in the

medical record. The total time spent on both testing and interpretation with the report was documented at 65

minutes, not including the E/M service, which was documented as 20 minutes.

III.

DOCUMENTATION GUIDELINES

96110

Each administered developmental screening instrument is accompanied by scoring and documentation (eg, a

score or designation as normal or abnormal). This is often included in the test itself, but these elements may

alternatively be documented in the progress report of the visit. Since 96110 does not have any physician work,

this can all be done by clinical staff. Physicians are encouraged to document any interventions based on

abnormal findings generated by the tests.

CPT

ICD-10-CM

99213-25* Office service, established patient,

20-

29 mins

F90.1 Attention-deficit hyperactivity disorder

F80.2 Mixed receptive-expressive language disorder

96112 Developmental testing, first hour

F90.1 Attention-deficit hyperactivity disorder,

predominantly hyperactive type

F80.2 Mixed receptive-expressive language disorder

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96112-96113

In general, the documentation of developmental testing includes the scoring, interpretation, and development

of the report. This typically includes all or some of the following: identifying data, time and location of testing,

the reason for the type of testing being done, and the titles of all instruments offered to/completed by the child;

presence (if any) of additional persons during testing, child’s level of cooperation and observations of child’s

behavior during the testing session. Any assistive technology, prosthetics, or modifications made to

accommodate the child’s particular developmental or physical needs should be described, and specific notations

should be made if any items offered resulted in a change in the child’s level of attention, willingness to

participate, and apparent ease of task accomplishment. The item results should be scored, and the test protocol

and any/all scoring sheets should be included in the medical chart (computer scanning may be needed for

electronic medical records). An interpretation should be recorded, and a notation should be made for further

evaluation or treatment of the patient or family. A legible signature should also appear. The total time spent on

these services for the patient is required. If time is not documented, the code(s) may not be reported.

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Emotional/Behavioral Assessment

96127 Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder

[ADHD] scale), with scoring and documentation, per standardized instrument

Because clinical staff typically performs the 96127 service, the Medicare RBRVS relative values reflect only the

practice expense (clinical staff time, medical supplies, medical equipment) and professional liability insurance --

there is no physician work value published on the Medicare physician fee schedule for this code.

On the less common occasion where a physician performs this service, it may still be reported with code 96127,

but only the ordering would count under the data point for MDM. Do not include the time spent administering

the test in the time for the E/M service. When an assessment is performed along with any E/M service (eg,

preventive medicine or office outpatient), both the 96127 and the E/M service should be reported and modifier 25

(significant, separately identifiable evaluation and management service by the same physician on the same day

of the procedure or other service) should be appended to the E/M code to show the E/M service was distinct and

necessary.

When to Report Emotional/Behavioral Assessment

The frequency of reporting 96127 (emotional/behavioral assessment) is dependent on the clinical situation. The

AAP Bright Futures “Recommendations for Preventive Pediatric Health Care” schedule recommends

developmental/behavioral surveillance at each health supervision visit, and a formal assessment for depression

is recommended at every annual visit beginning at age 12 with a validated/standardized* assessment instrument

to improve detection of depression at the earliest possible age to allow for appropriate intervention services. The

AAP clinical report “Promoting Optimal Development: Screening for Behavioral and Emotional Problems”

provides additional guidance for emotional/behavioral screening.

Thus, the use of assessment instruments as a screening mechanism enhances the task of identifying those who

may be suffering from an emotional or behavioral disorder. The exact frequency of testing, therefore, depends on

the clinical setting and the provider’s judgment as to when it is medically necessary. When physicians ask

questions about a patient's emotional or behavioral health as part of the general informal history (eg,

surveillance), this is not a formal "screen" and, therefore, not separately reportable.

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Developmental Screening versus Emotional/Behavioral Assessment

At first glance, it may be difficult to discern if a standardized* instrument falls under a developmental screen

(96110) or an emotional/behavioral assessment (96127). Developmental screening really takes a look at a

patient’s overall development and will include questions on motor skills, language skills, and cognitive function,

as well as may include questions on social, emotional, and behavioral issues.

On the other hand, emotional and behavioral questions are being asked as part of an overall developmental

inventory. An emotional or behavioral assessment instrument will look specifically at behavior and emotional

health related to key symptoms of those conditions classified as behavioral or emotional conditions, such as

ADHD, depression, or anxiety.

96127 Vignette # 1

A 12-year-old girl presents with her dad for her annual preventive medicine service. The patient’s history and

interview do not show any concerns of depression; however, following Bright Futures guidelines, the patient is

given a screening instrument. The patient answers the questions, and the screen is normal.

96127 Vignette #2

A seven-year-old boy with previously diagnosed ADHD is being seen for a preventive medicine visit. At the end

of the visit, the father asks if he can discuss the patient’s ADHD medication. The father handed over 2 ADHD

assessments completed two weeks ago by his classroom teacher and tutor. The pediatrician gives these to the

medical assistant to score while you obtain more interim history. After reviewing the scored form and

discussing the results, it is decided to increase his stimulant medication. A follow-up appointment is scheduled

for four weeks. Medical decision-making (MDM) is of moderate complexity.

*NOTE: Some payers may also require the 96127 to be reported in 2 units on one-line item.

The Affordable Care Act and Standardized Screening

There is confusion as to whether codes 96110 and 96127 fall under the no cost-sharing provision in the

Affordable Care Act (ACA). The answer is - it depends. Only those services performed as part of routine

screening services as either recommended under the United States Preventive Medicine Services Task Force

(Recommendation A or B) or under the AAP Periodicity Schedule are covered as part of the ACA no cost

sharing.

CPT

ICD-10-CM

99394-25* Preventive medicine service established

patient, age 1-4

Z00.121 Encounter for routine child

health examination

96127 Emotional/Behavioral Assessment

Z13.31 Encounter for screening for depression

CPT

ICD-10-CM

99393-25* Preventive medicine service established

patient, age5-11 years

Z00.121 Encounter for routine child health

examination w/abnormal findings

99213-25

Moderate MDM

F90.2 Attention-deficit hyperactivity disorder,

combined type

96127 (2 units) Emotional/Behavioral Assessment

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However, when 96110 or 96127 is performed and reported as part of a diagnostic service (ie, a problem is

suspected) or when the screen is done outside of the routine recommendations (ie, more than the

recommendations stipulate), the codes may fall under a cost-sharing arrangement. Of course, any plan that is

not required to follow ACA provisions will have its own rules. One way to ensure that the developmental or

emotional/behavioral screen service is covered under ACA provisions (as appropriate) is to link the service to

either the “well baby/child” ICD-10-CM code or the “screening for” code. Note that in order to report the

“screening for” ICD-10-CM code, the patient has to be asymptomatic.

Health Risk Assessment

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96160 Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with

scoring and documentation, per standardized instrument

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96161 Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the

benefit of the patient, with scoring and documentation, per standardized instrument

Because clinical staff typically performs the 96160/96161 service, the Medicare RBRVS relative values reflect only

the practice expense (clinical staff time, medical supplies, medical equipment) and professional liability

insurance -- there is no physician work value published on the Medicare physician fee schedule for these codes.

A less common occasion where a physician performs this service it may still be reported with code 96160/96161,

but only the ordering would count under the data point for MDM. Do not include the time spent administering

the test in the time for the E/M service. When an assessment is performed along with any E/M service (eg,

preventive medicine or office outpatient), both the 96160/96161 and the E/M service should be reported and

modifier 25 (significant, separately identifiable evaluation and management service by the same physician on

the same day of the procedure or other service) should be appended to the E/M code to show the E/M service was

distinct and necessary at the same visit.

When to Report Emotional/Behavioral Assessment

The frequency of reporting 96160/96161 (health risk assessment) is dependent on the clinical situation. The AAP

Bright Futures “Recommendations for Preventive Pediatric Health Care” schedule recommends formal health

risk assessments throughout a patient’s life. For example, maternal depression screening (96161) is

recommended at 1 - 6 months visits with a validated/standardized* instrument. In addition, standardized* risk

assessments for alcohol or tobacco use (96160) may also be separately reported.

Social determinants of health risk assessments would also fall under these codes. Whether to choose 96160 versus

96161 depends entirely on what is being assessed. For food insecurity, the code would be 96160. For environmental

assessments, including risk factors associated with living situations, again choose 96160.

Unless the assessment focuses solely on the caregiver (as in maternal depression screening billed under the

baby), the code is 96160.

96161 Vignette

A 3-week-old established patient presents with her mom for a preventive medicine service. The mother is

asked to complete a maternal depression screen, which is negative.

CPT

ICD-10-CM

99391-25* Preventive medicine service established

patient, age 1-4

Z00.111 Health examination for newborn 8 to 28

days old

96161 Caregiver risk assessment

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96160 Vignette

A 2-year-old patient presents for their preventive medicine visit. During the encounter, the caregiver is asked

to complete a standardized* food insecurity inventory. It is positive. The caregiver is given some community

resources and the chart is flagged for follow-up with the caregiver.

CPT

ICD-10-CM

99392-25* Preventive medicine service established

patient, age 1-4

Z00.121 Encounter for routine child health

examination w/abnormal findings

96160 Patient risk assessment

Z59.41 Food insecurity