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How do I bill and code for PEDS and/or PEDS:DM? How can I get reimbursed for screening?

You may need to use the following:

  1. Attach the - 25 modifier to your preventive service code or E/M service code (to denote the office visit is a separate service from the screening.Then list 96110 times the number of screens given, e.g., X 3 if using PEDS+PEDS:DM+MCHAT. [Note that some States (e.g., North Carolina) does not allow an unbundled 96110 but has increased reimbursement substantially for the entire well-visit]. If billing a private payer, particularly Cigna, the -59 modifer is usually required instead of -25
  2. Multiple units, with the modifier appended to the visit as described above, best describe the separate entity of performing multiple 96110s. For insurers not accepting units, the distinct procedural service of each test is best represented with - 59 modifier appended to each additional unit of 96110:

    Example: A level 3 office visit in which three developmental screening instruments were administered, scored and interpreted:<>br> 99213
  3. Appeal all denied claims--sometimes State Medicaid Directors aren't aware of the federal ruling from 2005, in which the Centers for Medicare and Medicaid Services published a total relative value unit (RVU) of 0.36 for 96110, which amounts to a Medicare payment of $13.64. For Cigna and many other private payers, reimbursement is about $20.00. This RVU represents only malpractice expense and office expense --no physician work is included--meaning that screening is largely a staff function except for explaining results to families.

None of this can guarantee that a valid claim will be accepted, so the American Academy of Pediatrics (AAP) is willing to help with denied claims via their Coding Hotline: 800-433-9016, ext. 4022, or at

96110 or 96111 procedure codes will not cover the Denver because it is not validated.

How do I code a screen when the result is normal and will I get reimbursed?

This answer is provided from Linda Walsh at the AAP's Office of Coding and Reimbursement and Dr. Lynn Wegner, Chair AAP Section on Developmental and Behavioral Screening):

There are two levels of coding: optimal coding and acceptable coding. While optimal coding would indicate that you link the V79.3 or V20.2 code to 96110 in a patient that screens as "normal," payors do vary on their tendency to (financially) recognize such reporting. A coding purist would tell you to continue to report that code combination and fight it at the contractual level. That's a viable long term solution (and one that should be taken into account when your contract next comes up for renewal) but it doesn't work well in the short term (ie, mid-contract). Therefore, if you find that your payors are not recognizing that code combination, we suggest that you engage an acceptable coding alternative, such as seeing if a code in Chapter 16 of ICD-9-CM (Symptoms, Signs, and Ill-Defined Conditions) is a reasonable alternative. So, Developmental screening ICD-9 codes are all v codes, unfortunately. For example, Screening for: developmental handicap V79.9 (Screen developmental problems V79.c)in early childhood V 79.3 Now, if you had documented in the chart any reported delays (despite normal results after the screening), you could use: 783.42 Delayed Milestones 315.8 Other specific Delays in Dev 315.9 Unspecified Delays in Dev AFTER, the screening (ie next visit) you could NOT use these three codes as you would have screened 'normal'.

What are the best diagnosis codes to use for problematic PEDS/PEDS:DM results?

Commonly used ICD-9 codes are those sufficiently vague as to not interfere with a more complete diagnoses made by those to whom you refer.

Commonly Used Diagnosis Codes in response to screening test results include:
783.4 - Developmental Delay
309.23 - Academic Inhibition (school problems)
315.4 - Developmental Coordination Disorder
784.5 - Other Speech Disturbance
309.3 - Disturbance of Conduct