96110 Update, 1Q 2011

A request was made on SOAPM for a better understanding of the payment for developmental screening, namely the 96110 and 96111.  Here’s the update for 1Q 2011, where we examined tens of thousands of 9611X CPT codes used by our clients.

  •  The average charge for the 96110 was $42.02 with a low of $10 and a high of $200.  For the 96111, which is much less common, the average is $197 with a low of $150 and high of $250.I find this range of pricing a bit troubling. A 2000% spread?! I realize that the Medicare rate is something like $7-8, but I feel as though some practices are afraid to charge appropriately.
  • The average payment for the 96110 was $13.29. The average total payment was $14.34…which indicates that personal money is still paying for about 8% of these “covered” services.For the 96111, the average insurance payment is $115 and average total payment is $145, or a 25% difference.
  • A significant majority of the 96110s billed by our clients have modifiers on them, most often the -59, however the -25, -76, and -U1 or -U2 modifiers (?!?!) make an appearance, too. Perhaps our clients in the northeast can elighten me on the -U1/2 modifiers.
  • Here’s the biggie: we have only 4% of the codes submitted as being rejected by the inscos with no payment. However, what we don’t capture here are all the times our practices don’t bill for the code because they don’t bother. You know how I feel about that – you’ll NEVER get paid if you don’t bill for it – but it still happens that way a lot.

To be clear about this sample: it’s from the first 3 months of 2011. I have removed any 9611Xs with “no insurance” on them, so this is all for covered patients. There may be visits that are not yet paid, but given that it’s August now, it’ll amount to very little.

Meanwhile, I recommend checking out The Verden Group’s Payer Policy Search, which just launched.  You can learn whether your payer covers the 96110 or not…at least, according to their own published policies…

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