96110

Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

CPT code 96110 represents a developmental screening service typically performed during pediatric visits to evaluate a child's acquisition of age-appropriate developmental milestones. The objective of this screening is to identify potential developmental delays across various domains, including gross and fine motor skills, expressive and receptive language development, cognitive abilities, and social-emotional functioning. This code is explicitly used when a standardized, validated screening instrument is administered, scored, and documented. Examples of such standardized tools include the Ages and Stages Questionnaire (ASQ), the Modified Checklist for Autism in Toddlers (M-CHAT), the Parents' Evaluation of Developmental Status (PEDS), and the Denver Developmental Screening Test. The process begins with the provision of the screening instrument to the patient's parent or caregiver, who may complete it independently or with the assistance of the healthcare staff. After completion, the healthcare provider or trained clinical staff scores the instrument using the specific standardized rubric associated with the tool. The provider then interprets the numerical or categorical score to determine if the child is progressing normally or falls into a risk category warranting further evaluation or early intervention services. Following the scoring, the physician or qualified healthcare professional integrates these findings into the patient's medical record, ensuring that both the name of the standardized instrument and the exact score or interpretation are clearly documented. Importantly, this screening procedure is distinct from more complex neurodevelopmental testing or comprehensive behavioral assessments, which involve direct face-to-face interaction and testing by a psychologist or specialized physician. CPT 96110 is often billed alongside a preventive medicine service, utilizing a modifier 25 on the Evaluation and Management code if appropriate, to reflect the additional work of utilizing the standardized tool above and beyond the standard clinical interview and physical examination. Early identification through CPT 96110 allows for timely referral to speech therapy, occupational therapy, physical therapy, or specialized developmental pediatricians, significantly improving long-term developmental outcomes for pediatric patients.

Clinical Indications

  • Routine preventative care and well-child examinations typically at 9, 18, and 24 or 30 months per American Academy of Pediatrics guidelines.
  • Screening for autism spectrum disorder in toddlers typically at 18 and 24 months.
  • Parental concerns regarding a child's speech, language, or motor skill development.
  • Follow-up assessment for premature infants at high risk for developmental delays.
  • Assessment of a child presenting with behavioral issues potentially linked to underlying developmental deficits.

Procedure Steps

  1. Identify the clinical need for developmental screening based on age-specific guidelines or parental concern.
  2. Select an appropriate, validated, and standardized screening instrument (e.g., ASQ, M-CHAT).
  3. Administer the questionnaire to the parent, caregiver, or directly assess the child, depending on the tool design.
  4. Review the completed instrument to ensure all questions were answered accurately and completely.
  5. Score the instrument using the standardized methodology provided by the test publisher.
  6. Interpret the generated score to determine if the child is meeting developmental milestones or requires further evaluation.
  7. Discuss the screening results and any necessary referrals or interventions with the parent or caregiver.
  8. Document the specific instrument used, the score, the interpretation, and the plan in the electronic health record.

Coding Guidelines

  • Code 96110 is reported per standardized instrument. If multiple distinct standardized instruments are used, the code may be billed multiple times, often requiring modifier 59.
  • When billed on the same day as a preventive medicine service or an office visit, append modifier 25 to the Evaluation and Management code to indicate a significant, separately identifiable service.
  • Do not report 96110 for subjective, non-standardized milestone checklists or clinical interviews alone; a standardized, validated tool must be used.
  • Do not confuse 96110 with 96112 or 96113 for developmental test administration, or 96127 for brief emotional or behavioral assessment.
  • The medical record must explicitly state the name of the standardized instrument used, the score, and the interpretation to support billing.

Associated ICD-10 Codes