Mental Health & Developmental Screenings: A Refresher

Based on our experience, there is a good deal of confusion over the CPT codes for mental health and developmental screenings. It’s important to understand them and when to use them, not least because some payors are expanding coverage for these services.[1]

So let’s take a quick refresher course on these important codes. This week, we’ll discuss the first set of codes in this group. In our next issue, we’ll cover the others.

96110

This developmental screening is performed mainly during physicals for children from birth to age 18. During the screening, the provider asks the adult accompanying the child to detail their observations of the child’s skills (older children can be allowed to contribute their own observations).

The screening, which involves standardized testing instruments, documents developmental milestones, such as walking, talking, and learning. For older children, providers may document particular skills such as concentration, inability to stay still, hyperactivity, and learning ability, and order further testing as warranted. In this way, physicians can provide the necessary therapies (such as speech/language therapy or work on gross motor and fine motor skills) to assist their patients.

96112

Use this code if a physician or other qualified health professional performs developmental tests, including assessment of fine/gross motor skills, language, cognitive level, and social, memory, or executive functions. The testing must involve standardized developmental psychometric instruments and include interpretation and reporting. The 96112 code applies to the first hour of testing.[2]

96113

Related to 96112, apply this code for each additional 30 minutes of testing.

96127

This emotional/behavioral assessment is used for adolescents ages 12 to 18. It involves a standardized testing instrument, with scoring and documentation, and covers such conditions as depression, anxiety, and the attention-deficit/hyperactivity disorder (ADHD) scale.[3]

Documentation

Your documentation for these screenings should include:

the date
patient’s name
name and relationship of the informant (if the person providing information is not the patient)
name of the testing instrument
score
name and credentials of the person administering the assessment

The physician should also document that he/she has reviewed the score and discussed the results with the patient and the patient’s family as part of the related E/M service.

[1] AAFP: “Four screening codes you should be using.” https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/screening_codes.html

[2] CPT® Code 96112 – Developmental and Behavioral Screening and Testing | CPT® Codes List (aapc.com)

Developmental Reporting (aap.org)

[3] CPT® Code 96127 – Developmental and Behavioral Screening and Testing | CPT® Codes List (aapc.com)

Got a question about E/M coding? We’d love to hear from you.