Developmental screening, surveillance, and assessment are often complemented by the use of special tests, which vary in length. In this article, we shared documentation guidelines that will help pediatricians on reporting developmental screening and testing services.
The use of developmental screening instruments of a limited nature is reported using CPT code 96110 (developmental testing; limited). Code 96110 is often reported when performed in the context of preventive medicine services, but may also be reported when screening is performed with other evaluation and management (E/M) services such as acute illness or follow-up office visits.
Extended developmental testing using standardized instruments is reported using CPT code 96111. This service may be reported independently or in conjunction with another code describing a separate patient encounter provided on the same day as the testing (e.g., an evaluation and management code for outpatient consultation). A physician or other trained professional typically performs this testing service.
Each administered developmental screening and the testing instrument is accompanied by an interpretation and report (e.g., 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 itself. Physicians are encouraged to document any interventions based on abnormal findings generated by the tests. Following are examples of appropriate documentation for some testing tools:
PEDS (Parents’ Evaluation of Developmental Status): This questionnaire is designed to identify any parent/primary caretaker’s concerns about birth through an eight-year child’s developmental attainment and behavioral/mental health concerns. There are eight specific domain queries and one asking, “please list any concerns about your child’s learning, development, and behavior” and a final “please list any other concerns.” The parent answers are scored into the risk categories of high, moderate, or low. The report form is included with the test.
ASQ (AGES AND STAGES Questionnaire): This parent-report instrument, covering ages 1 month through 60 months, includes objective information as the adult notes whether the child performs the skill identified. There are six questions in each of five domains: Communication, Gross Motor, Fine Motor, Problem Solving, and Personal-Social. All questions are scored on a point system, with summary scores indicating the need for further evaluation. The ASQ also has a nonspecific comprehensive section where general concerns are addressed. No score is provided for these answers, but the instrument developers note any “Yes” responses should also be referred.
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, the 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). A brief interpretation should be recorded and notation should be made for further evaluation or treatment of the patient or family. A legible signature should also appear.
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