How To Use CPT Code 96110

CPT 96110 describes the process of developmental screening using a standardized instrument to assess a patient’s developmental milestones and speech and language skills. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 96110?

CPT 96110 is used to describe the screening process for developmental disorders in patients. It involves the use of a standardized instrument to assess various areas of development, such as language abilities, cognitive skills, motor skills, and social interaction. The provider administers the test and scores the results to determine if further evaluation is necessary.

2. Official Description

The official description of CPT code 96110 is: ‘Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument.’

3. Procedure

1. The provider uses a validated and standardized instrument to screen the patient for developmental disorders.
2. The screening focuses on areas such as developmental milestones, speech, and language skills.
3. The provider administers the test and scores the results.
4. If the screening indicates a potential issue, further evaluation may be recommended.
5. The provider documents the results of the screening and any recommendations for further evaluation.

4. Qualifying circumstances

CPT 96110 is appropriate for patients who require screening for developmental disorders. This may include children who are not meeting age-appropriate milestones or individuals who exhibit speech and language delays. The screening must be performed using a standardized instrument, and the provider must score and document the results.

5. When to use CPT code 96110

CPT code 96110 should be used when a patient undergoes developmental screening using a standardized instrument. It is important to note that this code is specifically for screening purposes and should not be used for developmental testing or emotional/behavioral assessments. If the screening indicates a need for further evaluation, additional codes may be used to report those services.

6. Documentation requirements

To support a claim for CPT 96110, the provider must document the following information:

• The specific standardized instrument used for the screening
• The date of the screening
• The results of the screening, including any areas of concern
• Any recommendations for further evaluation or intervention
• The provider’s signature

7. Billing guidelines

When billing for CPT 96110, ensure that the screening is performed using a standardized instrument and that the provider scores and documents the results. It is important to note that CPT code 96110 should not be reported with codes for developmental testing or emotional/behavioral assessments. Additionally, it is essential to follow any specific billing guidelines provided by payers to ensure accurate reimbursement.

8. Historical information

CPT 96110 has undergone some changes over the years. On January 1, 2015, the code was updated to include interpretation and reporting of the screening results. Prior to that, on January 1, 2012, the code was modified to specify limited developmental testing. The code was initially added to the CPT system on January 1, 1996.

9. Examples

1. A pediatrician using a standardized instrument to screen a 2-year-old child for developmental delays.
2. A speech therapist administering a developmental milestone survey to assess a child’s language abilities.
3. A psychologist conducting a speech and language delay screen for a 5-year-old with suspected communication difficulties.
4. An occupational therapist evaluating a child’s fine and gross motor skills using a recognized form.
5. A developmental specialist assessing a child’s social interaction skills using a standardized instrument.
6. A school psychologist screening a student for cognitive abilities and developmental milestones.
7. A neurologist using a standardized instrument to evaluate a patient’s language skills and cognitive abilities.
8. A speech-language pathologist assessing a child’s speech and language development using a recognized form.
9. A developmental pediatrician screening a child for developmental disorders using a standardized instrument.
10. A clinical psychologist evaluating a child’s social interaction skills and cognitive abilities using a recognized form.