Changes to CPT codes for structured screenings and brief assessments have led some payers to expand coverage for these services. Quality initiatives that include incentives for performing and reporting recommended screenings and assessments are an additional reason to familiarize yourself with these four codes:
• 96110, “Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument,”
• 96127, “Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder scale), with scoring and documentation, per standardized instrument,”
• 96160, “Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument,”
• 96161, “Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument.”
Codes 96110, 96160, and 96161 are typically limited to developmental screening and the health risk assessment (HRA). However, code 96127 should be reported for both screening and follow-up of emotional and behavioral health conditions.
Documentation of a structured screening or assessment should include the date, patient's name, name and relationship of the informant (when information is provided by someone other than the patient), name of the instrument, score, and name and credentials of the individual administering the instrument. In addition, the physician must document that he or she reviewed the score in the context of the patient presentation and discussed the results with the patient/family as part of the related E/M service. A few payers do indicate that a report (separate from the E/M service documentation) is also required, so verify your payers' documentation requirements prior to providing these services.
Adapted from “Getting Paid for Screening and Assessment Services.”
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