96110 Coverage During Well Visits

This blog is going to raise more questions than it answers, but one let’s get one of the few clear answers we have out of the way: pediatricians do not appear to follow Bright Futures’ periodicity schedule for developmental screening.  I realize that may not shock many of you, but you might be shocked to see how far apart the standard of care and the recording of that care really are.

A little background: at PCC, we are working on expanding the clinical measure aspect of our dashboard and we got the “bright” idea to provide feedback relating to the BF periodicity schedule. Experience tells us that there is a wide range in the delivery of such simple and understood necessities as vision and hearing screening that we expected developmental screening to have similar challenges.  In other words, where we expect to see a vision and hearing screen performed at, say, every 4y and 5y visit, we simply don’t.  And that, IMO, is crazy. At PCC we want to fix the issue of clinical inconsistency and missed opportunity – we want every child to get the entire suite of BF expected services.  It’s good medicine and it’s good for the practice.

Developmental screening has three expected appearances in early childhood – at 9, 18, and 30 months.  At each of these visits, we should see a 96110 CPT.  What do we actually see?

Whoa.
Click on the image if you want a closer look, but the story being told here is that pediatricians record a 96110 at only 38% of all 9m old visits, 72% of all 18m visits, and 38% of all 30m visits.  What’s going on here?  As I said, this raises more questions and provides answers, but here are some details of the data for those who want to drill into it:

  • Sample size?  ~800,000 well visits over the last year, so that’s not really an issue.  And these are better-performing practices.
  • We are aware that some practices are using a 99420 (either out of necessity or mistake), so we’ve included that code just to be safe.  We also know that a minority of practices are already using the new 96127 code – and even though that’s supposed to be for behaviorial screening specifically (i.e., your Vanderbilts), we threw that in too.
  • We are only measuring how often the developmental screening codes are billed – we aren’t measuring how often they are recorded in the EHR or performed and not recorded.  This difference is subtle, but important.  Ultimately, we are underestimating the real use of this service, but probably not enough to explain what’s going on.
  • What is going on?  Clearly, pediatricians have some understanding about using developmental screening tools in the 18-24m time frame, but that’s about it.  Yes, there’s a measurable jump at 9m, but those pediatricians are still in the minority.  And we’ve heard from a number of our clients who explain that they don’t do the 30m visit (for a variety of reasons, none of which I support), so they squeeze in another screening at 24m.
  • I know a number of practices who don’t like any of the billable tools, so they use a variety of their own screening methodologies.  I understand why they do this, but I can’t support the use of non-standardized tools. But don’t take my word for it, listen to the pros.

I’d like to hear from anyone who can shed some light on what we see here.

18 replies
  1. Josh Tardy
    Josh Tardy says:

    MCHAT’s are free. They are only valid at 18-24 months. That may explain a fair amount of the uptick at 18 months. You can support that theory by looking at 24 months and seeing the high usage again. I think that may be a big chunk. At my practice we have only managed to implement MCHATs, not other screening. -Josh Tardy, San Antonio

    Reply
      • Josh Tardy
        Josh Tardy says:

        Good point, I did not remember that MCHAT valid at 30 months. I still think that the MCHAT could partly explain the huge increase at 18 months. It’s cheap, easy, well known to peds, and NOBODY wants to miss Autism diagnosis.

        I really don’t understand why the 30 month visit isn’t a much higher %. I know many peds who don’t do 30m/o visits (me included) and I generally perceive them as late adopters. therefore I would have considered those doing 30m/o visits to high a higher ration of 96110 per WCC than is seen on the chart. PS. I know you will tell me why I need to do a 30m/o visit and I will soon…. not the point here.

        Reply
        • Josh Tardy
          Josh Tardy says:

          I just looked at BF guidelines and recalled that they only list autism screening at 18m and 24m, not 30m. That is why I was remembering those validity dates. Wonder if insco would consider “autism screening” different than “developmental screening” in regards to ACA law and potentially recoup. They LOVE to request medical documentation for 96110s for my group.

          https://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf

          JT

          Reply
          • Chip Hart
            Chip Hart says:

            That’s a good question; in theory, you should have both the autism and developmental screening done at the 18m. I bet many practices split those between the 18 and 24m.

        • Chip Hart
          Chip Hart says:

          I didn’t post the data, but the volume of 30m visit totals among pediatricians is also quite low relative to the other ages. So, when our data shows that 38% of those visits have screening done, it’s 38% of a much smaller number than the 24m or 36m. The implication, imo, is that kids >24m are not receiving enough standardized developmental screening, period.

          Reply
  2. Jan Loeffler
    Jan Loeffler says:

    I don’t understand why more are not using these screens and they are easy to do and reimbursable although could be more.
    Chadis.com has been a really great resource for a number of other screens and I hope PCC EHR will integrate with them sooner than later and P.S. I have put this request in a number to times. I heard better numbers at a recent AAP conference in Orlando (more like 50%) but this is far from what I expect too from any physicians who take care of children as we know early intervention DOES WORK!! I am presently being a beta tester for SEEK PLUS with Chadis to do motivational interviewing for problems that are associated with child abuse (another cap I wear).
    IN GA is it required to do for MC and yet our numbers are low also.
    I know we are all struggling in Pediatrics, but remember who we are serving!! Dr. Jan Loeffler

    Reply
  3. Chris Oorbeck, CPC
    Chris Oorbeck, CPC says:

    We do ASQ-3 at 9, 18, and 24 months. We also do M-Chat at 18 and 24 months. Therefore, you should be seeing two 96110’s billed at 18 and 24 months. That may account for the increase at those ages.

    We also do the 96127 for our 11-18 year old population. We screen with SCARED and PHQ2, billing for two screenings at each WCC. We have found that Medicaid is paying for one, most commercial payers have placed this code in their behavioral health policy, and usually apply them to copay or deductible. When asked why, they say the code says “Brief emotional/behavioral ASSESSMENT (not screening) which would not be paid as part of a WCC.

    As far as the routine vision and hearing screening, insurance companies consider them part of the WCC, so they are not separately billable or payable.

    Thank you for the opportunity to contribute.

    Reply
    • Chip Hart
      Chip Hart says:

      Actually, we accounted for the extra 96110s by simply looking at how many well visits had AT LEAST ONE 96110. Those Vanderbilts, for example, that come with 2-3 instances, are counted only once.

      Meanwhile, insurance companies may consider vision and screening to be part of the WCC, but CMS and the rest of the world do not. I STRONGLY ENCOURAGE (what’s a polite way to say implore?) you to bill those codes even if they aren’t paid. I believe I’ve posted the data here, and I know I’ve reviewed it nonetheless, but vision and hearing screenings are paid regularly around the country. I could insert a 20 minute lecture here, but the summary remains: bill for it. Always.

      Thanks!

      Reply
      • Annette Nielsen, MD
        Annette Nielsen, MD says:

        I agree that they (vision/hearing) are considered a part of the WCC by most insurances. I also agree that they should be billed out. I really hate that as soon as the insurance companies deny ANYTHING those EOBS are no longer able to AUTOPOST in PCC therefore no longer helping us. So we don’t get additional reimbursement but I have to spend more on my billers to input the EOB with the denial. That is why we don’t bill fort. Lame? Maybe.

        Reply
        • Chip Hart
          Chip Hart says:

          As a result of the ACA, vision and hearing should be considered payable codes by every payer except those still grandfathered (a fair number, but far from most). If you are running into this problem, you should work with the AAP and fill out a Hassle Factor form ASAP.

          Reply
  4. Jack Steeples
    Jack Steeples says:

    When billing more than 1 unit of 96127 Aetna, Cigna, and Blue Cross are only allowing payment on 1 and denying as duplicates. After sending an appeal letter with notes to BCBS I get a denial stating, “exceeds maximum allowance that would be clinically appropriate.” Is there something I can do about this? Doesn’t seem fair in instances when our doctor has to review multiple Vanderbilt assessments from parents and teachers for a patient, but we only get reimbursed for 1.

    Thank you for your time, interesting blog

    ~Jack

    Reply
    • Chip Hart
      Chip Hart says:

      It’s not fair and it’s not correct on their part.

      First, you need to fight this at every turn. Take the BF periodicity schedule, copy it, and send it back to them along with a copy of the definition of a 96127 and the Vanderbilt tests. Have them tell you, in writing, where it states that >1 behavioural screening is wrong.

      Second, fill out the AAP’s Hassle Factor Form and/or call your state and national AAP representatives. The AAP has liasons with each of the major payers and can help fix this problem.

      Reply
      • Janice H. Loeffler, MD
        Janice H. Loeffler, MD says:

        I agree with Chip and pediatrics is getting the short end of the stick with every turn we take. We do more to take care of our patients than most others to try and recognize early the increasing number of mental health issues that are out there, but we get no recognition of this and then there are the lack of services to compound the problem. Just my 2 bits while I roast at the beach! Jan Loeffler

        Reply
  5. stewart
    stewart says:

    Schedule another visit to go over the screenings. Bill it out then. The patient will have to pay a copay or deductible, but you may get reimbursed. We do this with the Conner’s forms for ADHD screenings.

    Reply

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