Billing Guidelines for Developmental and Mental Health Screening and Assessment in Primary Care Table 1: Pediatric Screening/Assessments in Healthy Kids Preventive Health Schedule Recommendation from Healthy Kids Preventive Health Schedule Examples of Acceptable Standardized Tools Billing Guidelines Limitations Post-partum depression screening Screening recommended at 1, 2, 4 and 6 month well child checks. Providers may “pre-screen” with PHQ-2 to determine if a longer standardized screening tool is needed. Patient Health Questionnaire-9 Edinburgh Postnatal Depression Scale (EPDS) 96161: Caregiver-focused health risk assessment may be billed only when a standardized screening tool is used. PHQ-2 may not be billed. Billing should occur under child’s MA number 96161 will be reimbursed up to 4 units total per child through age 12 months. 0 units will be reimbursed age 13 months and older. Developmental screening Surveillance recommended at well child visit; use of standardized screening tool required for all children at 9, 18 and 24 months (and whenever concern). Ages and Stages Questionnaires (ASQ) Parents’ Evaluation of Developmental Status (PEDS) 96110: Developmental screening may be billed only when a standardized screening tool is used and results documented 96110 will be reimbursed up to 8 units total per child through age 5 years. 0 units will be reimbursed age 6 years and older. A maximum of 2 of 96110 will be reimbursed per visit when both a general developmental screen and an autism screen are conducted; OR 96110 may be combined with other screening codes when appropriate (ex. 96127) for a maximum of 2 units of screening reimbursed per visit Autism screening Surveillance recommended at every well child visit; use of standardized screening tool required for all children at 18 and 24 Modified Autism Checklist in Toddlers, Revised with Follow-up (MCHAT-R/F): 16-30 months 96110: Developmental screening may be billed only when a standardized screening tool is used and results documented 96110 will be reimbursed up to 8 units total per child through age 5 years. 0 units will be reimbursed age 6 years and older. A maximum of 2 units of 96110 will be reimbursed per visit; OR
months (and whenever concern). 96110 may be combined with other screening codes (ex. 96127) for a maximum of 2 units of screening per visit Mental health/ behavioral assessment Annually beginning at 3 years of age. Use of standardized screening tool is recommended. Pediatric Symptom Checklist (PSC-Y) Strengths and Difficulties Questionnaire (SDQ) Ages and Stages Questionnaire – Social Emotional (ASQ-SE) Early Childhood Screening Assessment 96127: Brief emotional/ behavioral assessment may be billed only when a standardized screening tool is used and results documented A maximum of 2 units of 96127 will be reimbursed per visit; OR 96127 may be combined with other screening codes (ex. 96110) for a maximum of 2 units of screening per visit Depression screening Screening recommended annually beginning at 11 years of age. If providers choose, they can with PHQ-2 to determine if a longer standardized screening tool is needed. PHQ-9 Modified for Teens Pediatric Symptom Checklist (PSC-Y) Center for Epidemiological Studies Depression Scale for Children (CES-DC) Beck Depression Inventory (BDI) 96127: Brief emotional/ behavioral assessment may be billed only when a standardized screening tool is used and results documented. PHQ-2 may not be billed. A maximum of 2 units of 96127 will be reimbursed per visit; OR 96127 may be combined with other screening codes (ex. W7000) for a maximum of 2 units of screening per visit Substance use assessment Annually beginning at 11 years of age; use of brief screening tool is recommended. Positive screens should be followed by brief intervention and referral for treatment when indicated (SBIRT: Screening, Brief CRAFFT CAGE-AID W7000: Alcohol and/or substance use disorder screening may be billed only when a standardized screening tool is used and results documented. W7020: Intervention; > 3 minutes up to 10 minutes A maximum of 1 unit of W7000 will be reimbursed annually for recipients age 11 and up may be combined with other screening codes (ex. 96127) for a maximum of 2 units of screening per visit A maximum 4 interventions will be reimbursed annually per recipient age 11 and up
Intervention, and Referral to Treatment) W7021: Intervention; >10 minutes up to 20 minutes W7022: Intervention; >20 minutes Table 2: Other Pediatric Mental Health Screening/Assessments Recommendation Examples of Acceptable Standardized Billing Guidelines Limitations ADHD Assessment AAP clinical policy recommends use of ADHD-focused parent and teacher ratings scales as a component of screening/diagnosis when there is concern Vanderbilt ADHD Diagnostic Rating Scales – Parent and Teacher Conners-3 Ratings Scales ADHD Rating Scale-5 for Children and Adolescents 96127: Brief emotional/ behavioral assessment may be billed only when a standardized screening tool is used and results documented. A maximum of 2 units of 96127 will be reimbursed per visit Other mental health screening/ assessment Disorder-focused mental health screening and assessment tools may be used when there is a specific concern, ex. anxiety Screen for Childhood Anxiety Related Disorders (SCARED) Spence Children’s Anxiety Scale 96127: Brief emotional/ behavioral assessment may be billed only when a standardized screening tool is used and results documented. A maximum of 2 of 96127 will be reimbursed per visit Table 3: Adult Screening/Assessments for Mental Health and Substance Use Recommendation Examples of Acceptable Standardized Tools Billing Guidelines Limitations
Depression screening Standardized screening tool is recommended; if providers choose, they can “pre-screen” with PHQ-2 to determine if a longer screen is needed Patient Health Questionnaire-9 Beck Depression Inventory (BDI) Brief emotional/ behavioral assessment may be billed only when a standardized screening tool is used and results documented. PHQ-2 may not be billed. 96127 may be combined with other screening codes (ex. W7000) for a maximum of 2 units of screening per visit Substance Use Screening Standardized screening tool is recommended Positive screens should be followed by intervention and referral for treatment when indicated (SBIRT: Screening, Brief Intervention, and Referral to Treatment) Alcohol Use Disorders Identification Test Drug Abuse Screening Test (DAST) Alcohol, Smoking, and Substance Involvement test (ASSIST) CRAFFT (under 21) W7000: Alcohol and/or substance use disorder screening, may be billed only when a standardized tool is used W7010: Alcohol and/or substance use disorder screening, provider administered may be billed only when a standardized provider administered tool is used W7020: Intervention; > 3 minutes up to 10 minutes W7021: Intervention; >10 minutes up to 20 minutes W7022: Intervention; >20 minutes A maximum of 1 unit of W7000 or W7010 will be reimbursed annually for recipients age 11 and up and W7010 may be combined with other screening codes (ex. 96127) for a maximum of 2 units of screening per visit A maximum of 4 interventions will be reimbursed annually per recipient age 11 and up Procedure Code Description Current reimbursement 2017