CPT code 96110
96110 CPT code in occupational therapy is the billing code for a "developmental screening (e.g., developmental milestone survey, speech, and language delay screen) with scoring and documentation, per standardized instrument," according to the American Medical Association.
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The screening asks the child's observer to provide observations of the child's skills, which an occupational therapist records on a standardized and validated screening instrument.
The AMA introduced the 96110 CPT code as a method for early detection of developmental delays.
With time, speech-language pathologists, psychologists, occupational therapists, and other healthcare professionals used the code.
What is CPT code 96110 used for?
Occupational therapists need to understand the 96110 CPT code as it falls within their scope of practice within the pediatric population. Understanding this code facilitates effective collaboration with other healthcare professionals, ensures accurate billing and reimbursement, supports compliance with healthcare regulations, and ultimately enhances the quality of patient care.
The AMA has updated guidelines over time to meet the ever-changing healthcare needs.
Key features of 96110 CPT code
Therapists can use standardized assessments that include the following:
Ages and Stages Questionnaire (ASQ) is a system of 21 age-specific screening questionnaires designed to assess the following child development areas:
- Gross motor
- Communication
- Problem-solving
- Personal-social
The Modified Checklist for Autism in Toddlers (M-CHAT) is a screener that asks 20 questions about a child's behavior between the ages of 16 and 30 months.
Denver Developmental Screening Test is a simple screening that identifies evidence of slow development in infants and preschool children. The test covers gross motor, language, fine motor-adaptive, and personal-social skills.
The Pediatric Evaluation of Disability Inventory (PEDI) assesses functional skills, level of independence, and the extent of modifications required to perform functional activities in young children. The assessment is geared toward children aged six months to seven years. The primary focus of the PEDI is on early detection of developmental delays and interpreting and documenting results.
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Billing and documentation tips for billing 96110 CPT code
Be sure to follow the following requirements for 96110 CPT code billing
- Each administration of a standardized tool is billed separately. If multiple screenings are used in the same visit, each should be documented and billed individually, according to payer regulations, and a modifier may be required.
- For example, if an occupational therapist performs multiple standardized screens on a patient (e.g., an M‐CHAT and ASQ), report 96110 with two units (or on separate line items). Modifier 59 may be required to indicate distinct services.
- Interpretation and documentation of results must include the following:
- Screening tool information
- Clinical reasoning for screening
- Date of screening
- Report with screening results, scores, clinical interpretation, and recommendations
- Patient/Caregiver communication
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Documentation pitfalls to avoid
Ensuring accurate documentation for the 96110 CPT code is essential for proper billing and reimbursement.
- Some general pitfalls to avoid during documentation include:
- Not enough documentation information
- Clerical errors such as typos
- Utilizing incorrect codes
- Incorrect billing information
Additionally, for CPT code 96110, it is important to document and bill each screening as appropriate and be mindful of specific payer regulations.
A step-by-step process for administering developmental and behavioral screenings
Below are the steps to follow for the administration of developmental screenings.
- Review occupational profile and history, obtain consent, and explain the purpose of screening and the steps of the process.
- Select and administer the appropriate standardized screening tool.
- Record observations and interpret scores and results.
- Identify areas of concern and need.
- Communicate findings to caregivers and collaborate with caregivers with an intervention plan.
- Set client-centered intervention methods.
- Offer resources and support networks.
- Coordinate with other healthcare professionals.
- Re-assess and re-evaluate as necessary.
Ethical and professional considerations
Ensuring ethical and professional screening standards incorporates using appropriate standardized tools, maintaining confidentiality, obtaining informed consent, and communicating appropriately and effectively with caregivers and family members. It also involves utilizing non-discriminatory principles, inclusive practice methods, and cultural sensitivity. By following these principles, therapists can provide client-centered care and high standards of care.
Challenges and strategies when using the 96110 CPT code
Some common challenges and limitations with using the 96110 CPT code include insurance reimbursement variability, time restrictions, training, competence, not providing a comprehensive picture and age limitations.
Some strategies to assist with the 96110 CPT code limitations include continuing education and training, utilizing culturally appropriate tools, communicating with parents and caregivers, validating with other assessment tools, and regularly reviewing insurance policies.
With these practices, therapists can overcome these challenges to ensure that children receive accurate assessments promptly.
Future trends and developments
Some emerging trends and research in developmental screening include a more personalized approach to screening, expansion of developmental conditions, development of new and updated tools, use of telehealth services and platforms, incorporation of artificial intelligence and machine learning, and use of digital and mobile screening tools.
With these future trends and developments, healthcare professionals can provide improved client-centered, holistic care in a personalized, accurate, and timely manner.
96110 CPT code plays a fundamental role in occupational therapy by providing a code for billing and documenting developmental screenings. It allows therapists to identify a child's potential developmental delay early, provide timely interventions, and assess and track developmental progress. Integrating and incorporating the 96110 CPT code into clinical practice is essential for delivering high-quality, client-centered, and evidence-based occupational therapy services.
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How EHR and practice management software can save you time with insurance billing for therapists
EHRs with integrated billing software and clearing houses, such as TheraPlatform, offer therapists significant advantages in creating an efficient insurance billing process. The key is minimizing the amount of time dedicated to developing, sending, and tracking medical claims through features such as automation and batching.
What are automation and batching?
- Automation refers to setting up software to perform tasks with limited human interaction.
- Batching or performing administrative tasks in blocks of time at once allows you to perform a task from a single entry point with less clicking.
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Which billing and medical claim tasks can be automated and batched through billing software?
- Invoices: Create multiple invoices for multiple clients with a click or two of a button or set up auto-invoice creation, and the software will automatically create invoices for you at the preferred time. You can even have the system automatically send invoices to your clients.
- Credit card processing: Charge multiple clients with a click of a button or set up auto credit card billing, and the billing software will automatically charge the card (easier than swiping!)
- Email payment reminders: Never manually send another reminder email for payment again, or skip this altogether by enabling auto credit card charges.
- Automated claim creation and submission: Batch multiple claims with one button click or turn auto claim creation and submission on.
- Live claim validation: The system reviews each claim to catch human errors before submission, saving you time and reducing rejected claims.
- Automated payment posting: Streamline posting procedures for paid medical claims with ERA. When insurance offers ERA, all their payments will post automatically on TheraPlatform's EHR.
- Tracking: Track payment and profits, including aging invoices, overdue invoices, transactions, billed services, service providers.
Utilizing billing software integrated with an EHR and practice management software can make storing and sharing billing and insurance easy and save providers time regarding insurance billing for therapists.
Resources
TheraPlatform is an all-in-one EHR, practice management, and teletherapy software built for therapists to help them save time on admin tasks. It offers a 30-day risk-free trial with no credit card required and supports different industries and sizes of practices, including occupational therapists in group and solo practices.
More resources
- Therapy resources and worksheets
- Therapy private practice courses
- Ultimate teletherapy ebook
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Guide to Starting a Private Therapy Practice
- Insurance billing 101
- Practice management tools
Free video classes
- Free on-demand insurance billing for therapist course
- Free mini video lessons to enhance your private practice
- 9 Admin tasks to automate in your private practice
References
- Ages and Stages Questionnaires. Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-measures/ages-and-stages-questionnaires
- American Academy of Pediatrics. Coding for Standardized Assessment, Screening, and Testing.
- American Medical Association. 2023 CPT® CODES FOR OCCUPATIONAL THERAPY.
- Frankenburg, W. K., and Dodds, J. B. (1967). The Denver Developmental Screening Test. The Journal of Pediatrics, 71(2), 181–191. https://doi.org/10.1016/s0022-3476(67)80070-2
- Modified Checklist for Autism in Toddlers, Revised (M-chat-RTM). Autism Speaks. https://www.autismspeaks.org/screen-your-child
- Pediatric Evaluation of Disability Inventory. Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-measures/pediatric-evaluation-disability-inventory
