Coding for Developmental and Behavioral Disorders
Pediatricians who provide care to children with developmental or behavioral disorders recognize the challenges not only in providing the care, but getting paid for their work. These services are very time intensive and coding for the work can be complex and confusing.
The American Academy of Pediatrics (AAP) has been working diligently to provide coding education to members and national payers for recognition of these vital services, and a new developmental and behavioral PediaLink® coding module has been developed. Included are tips for correct coding to help pediatricians receive payment for the services provided. PediaLink is an AAP-developed Internet-based continuing medical education system that facilitates the acquisition of new information in children’s and adolescent’s medical care. Self-contained modules not only provide current information, but also show how this information can be integrated into daily practice.
Evaluation and Management Codes Used to Report Developmental and Behavioral Services
The initial assessment may be performed on a new or an es-tablished patient or at the request of another physician or other appropriate source (eg, school nurse, teacher, psychologist). Typically these assessments require one or more lengthy visits to complete a comprehensive history or examination, perform or order testing, and determine a differential diagnosis. After the diagnosis is made, a treatment plan must be developed and counseling or coordination of care may be needed. The evaluation and management (E/M) code reported will depend on the type of service provided (new patient, established patient, consultation) and the key components (history, physical examination, medical decision making) of the E/M service performed and documented. If more than 50% of the total face-to-face E/M service is spent in counseling or coordination of care, the selection of the code will be based on the total face-to-face time.
Once the initial assessment has been performed, follow-up visits will be reported based on the performance and documentation of the key components of the service or, if more than 50% of the visit is spent in counseling or coordination of care, time.
9920199205 Office or other outpatient visit for the E/M of a new patient; requires 3 of 3 key components
9921299215 Office or other outpatient visit for the E/M of an established patient; requires 2 of 3 key components
9924199245 Office or other outpatient consultation for a new or established patient; requires 3 of 3 key components
If a consultation is reported, the request for consultation, whether verbal or written, must be documented in the medical record. The documentation must include the name of the requesting physician or other appropriate source and the reason or need for the request. The consultant must render an opinion or recommendation. Any services performed or ordered must be documented. A written report back to the requesting physician or other appropriate source must be included in the medical record. This report can be a letter or copy of the progress note.
Prolonged services may be reported when the physician provides services beyond the usual on the same date. Prolonged services may be face-to-face or without direct face-to-face patient contact. These services are reported in addition to any level of E/M service performed on a given date of ser-vice. The total duration of prolonged service time spent by the physician on a given date does not have to be continuous. The medical record must clearly reflect the total time spent face-to-face with the patient or parent or in coordinating care. Prolonged service of fewer than 15 minutes beyond the first hour or fewer than 15 minutes beyond the final 30 minutes is not reported separately.
99354 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual services; first hour (3074 minutes)
99355 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual services; each additional 30 minutes
Nonface-to-face services might include telephone communication with the family, other physicians, or heath care professionals involved in the patient care; community services to coordinate services and care; or review of extensive medical records and tests. These services must be performed and reported on the same date of service as the face-to-face E/M code.
99358 Prolonged E/M service before or after direct (face-to-face) patient care; first hour (3074 minutes)
99359 Prolonged E/M service before or after direct (face-to-face) patient care; each additional 30 minutes
Case Management Services
Case management service codes are used to report the physician’s involvement and time spent in initiating, coordinating, and supervising the health care services needed by the patient.
99361 Medical conference by a physician with an interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care; approximately 30 minutes
99362 Medical conference by a physician with an interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care; approximately 60 minutes
The patient is not present at these conferences. Because these are time-based codes, the medical record must reflect the total time spent at these conferences. Documentation should include details about the conference and outcomes.
Telephone calls made by a physician to a patient or other health professional can also be reported.
99371 Telephone call made by the physician to a patient or parent, for consultation or medical management, for coordination of medical management with other health care professionals; simple or brief
99372 Telephone call made by the physician to a patient or parent, for consultation or medical management, for coordination of medical management with other health care professionals; intermediate
99373 Telephone call made by the physician to a patient or parent, for consultation or medical management, for coordination of medical management with other health care professionals; complex or lengthy
Central Nervous System Assessment and Tests
96110 Developmental testing; limited, with interpretation and report
96111 Developmental testing; extended, with interpretation and report (includes assessment of motor, language, social, adaptive, or cognitive functioning by standardized developmental instruments)
A physician of any specialty can report these services. The use of developmental screening instruments of a limited nature (eg, Developmental Screening Test II, Early Language Milestone Screen, Parents’ Evaluation of Developmental Status, Ages and Stages, and Vanderbilt attention-deficit/ hyperactivity disorder rating scales) is reported using Current Procedural Terminology (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 E/M services such as acute illness or follow-up office visits. An office nurse or other trained nonphysician personnel performs this service; this code does not include any physician work. The review of the screening results is included in the preventive or E/M service. When physicians ask questions about a child’s development as part of the general informal developmental survey or history, this is not a formal measure as such and is not separately reportable.
Each administered developmental screening instrument is accompanied by an interpretation and report (eg, a score or designation as normal or abnormal). Normal results might be recorded as, "Mother has no significant concerns about her child’s fine motor, gross motor, expressive/receptive language, social interactions, or self-help skills." Abnormal results might be recorded as, "Mother has concerns about her child’s expressive language and articulation, but no significant concerns about his fine motor, gross motor, receptive language, social interactions, or self-help skills." These interpretive remarks may be included on the screening form or in the progress note of the visit itself. Physicians are encouraged to document any interventions or referrals based on abnormal findings generated by the formal screening. If several tests are administered, results may be combined into a single report. Recommendations for interventions and other supportive measures should be included in the report summarizing the test results.
When developmental surveillance or screening suggests an abnormality in a particular area, more extensive formal objective testing is needed to evaluate the concern. 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 not maintaining appropriate acquisition of new skills.
These longer, more comprehensive developmental assessments using standardized instruments are typically reported using CPT code 96111, developmental testing; extended. These are tests of development, typically performed by physicians or other specially trained professionals, for which the physician work is included as part of the service. Code 96111 includes the testing and an accompanying formal report.
The frequency of reporting code 96111 is dependent on the needs of the patient and the judgment of the physician. CPT code 96111 describes no more than 1 hour of face-to-face work and may not be reported more than once a day for the patient. If much less than a full hour is spent performing the service, append modifier 52, reduced services, to the procedure code.
When developmental testing is reported in conjunction with an E/M service, the time and effort to perform the developmental testing itself should not count toward the key components (history, physical examination, medical decision making) or time for selecting the accompanying E/M code. The E/M service should be reported with modifier 25 appended to reflect that the service was separate and medically necessary.
96116 Neurobehavioral status examination with interpretation and report
These tests are performed for the purpose of making a medical diagnosis. An example of a neurobehavioral status examination follows.
An 8-year-old girl is showing significant changes in her be-havior at home and school, including attention difficulties, memory problems, and difficulties with making decisions about common daily activities. Mother is concerned that the problems may be a result of the girl falling out of her crib when she was a toddler. The physician performs a neurobehavioral status examination that includes screening for impairments in attention and short-term memory, language, long-term memory, problem solving, and visual and spatial abilities. The physician observes the girl’s behavior and records her responses.
Health and Behavior Assessment and Intervention: Codes 9615096155
Health and behavior assessment and intervention codes are used by social workers, licensed therapists, psychologists, or other appropriate nonphysician providers to address behavioral issues that surround medical conditions. They are not used by physicians and are not applicable for services provided to patients with a psychiatric condition.
Health and behavior assessment is used to focus on the bio-psychosocial factors affecting physical health problems and treatment. Health and behavior intervention is used to improve the patient’s health and well-being by modifying factors directly affecting the patient’s disease management. These services are not used for preventive medicine counseling and risk factor reduction interventions.
These codes are significant only to those physicians who practice in states where insurers allow nonphysician providers to bill for their services independently or as incident to those provided by the physician.
Health and behavior assessment and intervention services are not reported with psychiatric services (9080190899), E/M services (9920199215), preventive medicine visits (9938199395), or preventive medicine risk counseling (9940199412) when performed on the same date of service. Any neuropsychologic testing performed is reported separately. The medical record must reflect the time spent in the activity or visit.
90862 Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy
This service is only reported when the physician manages medication for a patient undergoing psychotherapy by a nonphysician, when a patient is being treated by psychotropic drugs alone, or when the physician is managing a patient with the medication for an organic-type disorder. If an E/M service is provided at the encounter, pharmacologic management is considered an inherent part of the E/M service and is not reported separately. While 90862 is commonly used by psychiatrists for their medication management services, nonpsychiatrist physicians customarily have their medication management described by E/M codes.
99080 Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form
This code could properly be used for generating the report of a child’s developmental status if the information conveyed exceeded the mere reporting of the performance resulting from developmental testing (96111). Most payers do not cover this service.
Payers are likely to deny coverage for physician services including visits, developmental testing, and health and behavior assessments when they are reported with International Classification of Diseases, Ninth Revision, Clinical Modification codes 290319.9 because the payers incorrectly assume the services fall under a mental health carve out (services limited to mental health providers). Most currently do not cover necessary case management services including telephone calls and medical conferences. It is important for the pediatrician to educate payers on the scope and benefit of the services they provide. With education, payers may be more willing to negotiate for coverage and payment of these services.
Lynn Wegner, MD, FAAP, chairperson of the Section on Developmental and Behavioral Pediatrics, contributed to this article.