(469) 421-8216
CPT Code 96110 is used for developmental screening assessments that help identify delays or concerns in a child’s development. This code applies when a standardized instrument is used to evaluate areas like language, motor skills, social-emotional functioning, or cognitive development, and the results are scored and interpreted by a healthcare professional.
It’s commonly used in pediatric, behavioral health, or primary care settings during wellness visits or when concerns about developmental progress arise.
CPT Code 96110 - Description
96110 – Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument.
This code represents one standardized screening tool per administration, and can be reported multiple times if multiple tools are used during the same visit. The scoring and interpretation must be documented clearly in the patient's medical record.
When to Use CPT Code 96110 – Clinical Scenarios
CPT 96110 is used when standardized instruments are administered to assess developmental progress or concerns. Below are enhanced real-world scenarios for its use:
1. Routine Well-Child Visits
A 2-year-old child is brought in for a scheduled checkup. The pediatrician administers the Ages & Stages Questionnaire (ASQ-3) to screen for delays in communication, motor skills, and problem-solving. The parent completes the form, and the physician scores and reviews it as part of the assessment.
2. Speech Delay Concerns
Parents express concerns that their 3-year-old is not speaking as expected. The provider uses a validated language screening tool, such as the PLS Screener, scores it, and uses the results to determine if further evaluation is necessary.
3. School Performance Issues
A 5-year-old child is referred for behavioral and developmental concerns affecting school performance. A combination of tools like the SWYC or PEDS is administered to assess social-emotional and cognitive function.
4. Re-screening After Initial Concerns
A child who previously screened at-risk is returning for follow-up. The provider re-administers the same tool to track progress and adjust the care plan based on updated scores.
5. Screening in Behavioral Health Settings
In a mental health clinic, a developmental screener is used before initiating therapy for a child presenting with behavior challenges to ensure delays aren’t contributing to emotional dysregulation.
Documentation Requirements (H3 with Paragraph-Style Explanation)
Standardized Tool Used
Clearly state the name of the validated instrument used for the developmental screening (e.g., ASQ, PEDS, M-CHAT). This is required to prove the service meets clinical standards.
Who Completed the Tool
Document whether the parent, caregiver, teacher, or provider completed the screening instrument.
Scoring and Interpretation
Indicate that the tool was scored and interpreted by the clinician. This validates that the assessment meets the CPT requirement of provider-level review.
Clinical Findings or Risk Level
Briefly explain what the screening revealed (e.g., "results indicate mild delay in gross motor skills") and whether further assessment, intervention, or referral is needed.
Follow-Up Plan
Mention any next steps, such as early intervention referral, developmental therapy, or monitoring for re-evaluation.
Reimbursement Tips for CPT Code 96110
- Frequency: Often reimbursed once per visit, but may be billed multiple times if more than one tool is used (e.g., developmental + autism screener).
- Documentation is Key: Missing tool names or unscored assessments will lead to denials.
- Bundling Policies Vary: Some payers may bundle 96110 into preventive visits, while others reimburse separately.
- Medicaid Coverage: Widely reimbursed under Medicaid programs as part of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT).
- Commercial Plans: Coverage is more variable; verify in-network policies and frequency limits to ensure optimal coverage.
Typical Reimbursement Rates:
- Medicaid: $6–$12
- Private Insurance: $10–$25, depending on plan and documentation
Why Choose MindCare for Developmental Screening Billing?
At MindCare, we recognize the crucial importance of early detection in pediatric behavioral health and the frequent occurrence of undercoding or documentation gaps, which can result in lost revenue. We specialize in ensuring CPT 96110 is billed accurately, using payer-compliant methods to capture all eligible services.
From identifying appropriate screening opportunities to maintaining proper documentation and modifier use, our team ensures your practice is paid for the valuable work it performs during early development screenings.
Here’s How We Add Value:
- Accurate billing of age-specific screenings
- Payer-specific insights to avoid denials
- Integrated workflows for pediatric, behavioral, and family medicine settings
- Strategic coding to capture both preventive and diagnostic components
- Support for compliance with Medicaid EPSDT and commercial plan rules
Learn more about our complete Mental Health Billing Services to ensure every developmental assessment counts toward your revenue goals.
Let Mind Care Billing Help
We help mental health providers use the correct CPT codes, avoid denials, and get paid faster. If you're unsure which code to use, or tired of dealing with rejections, our team can take billing off your plate entirely.
Schedule a Free Consultation with Mind Care Billing today — and leave the coding confusion behind.
