Description

According to the Center for Disease Control and Prevention (CDC), approximately 13% of children aged 3 to 17 in the United States have a developmental or behavioral disability such as autism, intellectual disability and attention-deficit/hyperactivity disorder. In addition, many children have delays in language or other areas that can affect school readiness. However, fewer than half of children with developmental delays are identified before starting school, by which time significant problems have already occurred and opportunities for treatment might have been missed.

Early identification is required by federal law. The Individuals with Disabilities Education Act (IDEA) Amendments of 1997 mandate the “early identification of, and intervention for developmental disabilities through the development of community-based systems.” This law requires physicians to refer children with suspected developmental delays to appropriate early intervention services in a timely manner. All states receive federal funding to provide appropriate intervention through infant and child-find programs for children with developmental delays.

The American Association of Family Physicians (AAFP) and the American Academy of Pediatricians (AAP) agree that developmental delay screening is a necessary part of every child’s medical evaluation. The percentage of pediatricians who regularly screened young patients for developmental delays more than doubled from 2002 to 2009. There are a variety of available screening tools that can be completed by either medical staff or by the parents. (See Reimbursement Guidelines.)

Children whose screening scores demonstrate possible disability should receive more intensive assessment for the diagnosis of potential developmental delays. This involves testing to measure cognitive, motor, social, language, adaptive, and/or cognitive abilities using provider standardized tests. The results of a developmental delay test may determine if the child is in need of early intervention services and/or a treatment plan.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will provide coverage for developmental screening when the criteria outlined in this policy are met. 

Reimbursement Guidelines

Pediatric developmental delay screening is covered if the following criteria are met:

1. A validated screening tool is utilized, and
2. The tool is used in its entirety; using a subset of items is considered invalid, and
3. Medical records document the screening tool is scored and a separate identifiable report is prepared, and
4. Screening occurs at 6, 12, 18 or 24, 36, 48, and 60 months of age, or if concerns are raised by the parents during routine visits. Screening with the Modified Checklist for Autism in Toddlers (MCHAT) for autism is recommended to take place at 18 and 24 months.

Pediatric developmental delay testing is covered if screening demonstrates the possibility of disability and further assessment is required.

Pediatric developmental delay screening and/or testing is not covered if the above criteria are not met.

Preventative counseling for risk factor reduction for developmental delay and the administration of health risk assessment tools are not considered developmental delay screening or testing, and are not covered.

Rationale

The terms “delayed development,” “disordered development,” and “developmental abnormality” are used synonymously and refer to a childhood mental or physical impairment or combination of mental and physical impairments that result in substantial functional limitations.

According to the AAP policy statement “Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening,” “surveillance” is the ongoing process of identifying children who may be at risk of developmental delays, and “screening” is the use of standardized tools at specific intervals to support and refine the risk. Surveillance is considered integral to the regular well child E/M service and should not be billed separately. Screening may be billed separately from the regular E/M service. If more than one screening tool is completed in a single visit, Modifier 59 may be applied to each claim line.

Many screening tools are now available online and are printed in a number of different languages. Screening tools should have established psychometric qualities, such as sensitivity, specificity, and positive/negative predictive power. The following tools are suggested to be reliable and easy to use:

1. Parents’ Evaluation of Developmental Status (PEDS)
2. The Age and Stages Questionnaire (ASQ) system (formerly known as the Infant Monitoring Questionnaires)
3. Children’s Developmental Inventory (CDI)
4. The Battelle Developmental Inventory Screening Test (BDIST)
5. The Bayley Infant Neurodevelopmental Screener (BINS)
6. Modified Checklist for Autism in Toddlers (M-CHAT)

Developmental delay testing is an in-depth assessment of a child's skills and should be administered by a highly trained professional, such as a developmental psychologist, developmental pediatrician, or pediatric neurologist.

Preventative counseling for risk factor reduction and the administration of health risk assessment tools represent other clinical services, and are not considered equivalent to developmental delay screening or testing. 

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at Blue Cross NC.

If more than one screening tool is completed in a single visit, Modifier 59 may be applied to each claim line. 

The following CPT codes are not applicable for developmental delay screening or testing: 96160, 96161, 99411, 99412, 99429.

Related policy

n/a

References

Center for Disease Control and Prevention (CDC). Child Development/Developmental Monitoring and Screening. http://www.cdc.gov/ncbddd/childdevelopment/screening.html

Rydz D, Srour M, Oskoui, M, et al., Screening for Developmental Delay in the Setting of a Community Pediatric Clinic: A Prospective Assessment of Parent-Report Questionnaires. Pediatrics Vol. 118 No. 4 October 1, 2006. Screening for Developmental Delay in the Setting of a Community Pediatric Clinic: A Prospective Assessment of Parent-Report Questionnaires | Pediatrics | American Academy of Pediatrics (aap.org)

Limbos M, Joyce D. Comparison of the ASQ and PEDS in Screening for Developmental Delay in Children Presenting for Primary Care. 2011;32 (7): 499-510. Comparison of the ASQ and PEDS in screening for developmental delay in children presenting for primary care - PubMed (nih.gov)

Section on Developmental and Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics.2006;118:405-420. Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening | Pediatrics | American Academy of Pediatrics (aap.org)

Johnson CP, Myers SM, et al. Clinical Report: Identification, Evaluation, and Management of Children With Autism Spectrum Disorders. Pediatrics. 2007;120(5):1183–1215. Identification and Evaluation of Children With Autism Spectrum Disorders | Pediatrics | American Academy of Pediatrics (aap.org)

Pelletier H, Abrams M. The North Carolina ABCD Project: A New Approach for Providing Developmental Services in Primary Care Practice. July 2002. The North Carolina ABCD Project: A New Approach for Providing Developmental Services in Primary Care Practice (commonwealthfund.org)

Robins DL. The Modified Checklist for Autism in Toddlers (M-CHAT^™). M-CHAT^™ M-CHAT-R_F_Cover (autismspeaks.org)

Medical Director review 8/2012

Medical Director review 1/2014

Medical Director review 12/2014

Center for Disease Control and Prevention (CDC). Autism Spectrum Disorders (ASDs). Autism Spectrum Disorder (ASD) | Autism | NCBDDD | CDC: https://www.cdc.gov/ncbddd/autism/index.html

Unites States Department of Health and Human Services - Strengthen early childhood development and expand opportunities to help children and youth thrive equitably within their families and communities. Objective 3.2 | HHS.gov: https://www.hhs.gov/about/strategic-plan/2022-2026/goal-3/objective-3-2/index.html

History

9/18/12 New policy implemented. Pediatric developmental screening is covered if the following criteria are met: 1.a validated screening tool is utilized, and 2.the tool must be used in its entirety; using a subset of items is not considered valid, and 3.medical records document the screening tool is scored and a separate report is prepared, and 4.screening occurs at 6, 12, 18 or 24, 36, 48, and 60 months of age or if concerns are raised by the parents during routine visits. Screening with the Modified Checklist for Autism in Toddlers (MCHAT) for autism is recommended to take place at 18 and 24 months. Pediatric developmental delay testing is covered if screening demonstrates the possibility of disability and further assessment is required. Pediatric developmental delay screening and/or testing is not covered if the above criteria are not met. Preventative counseling for risk factor reduction or the administration of a health risk assessment tool is not considered developmental delay screening or testing and is not covered. Medical Director review 8/2012.

1/28/14 Medical Director review. References updated. Added information regarding coverage of preventive screenings to the “Benefits Application” section. (mco)

12/30/14 Policy category changed from “Corporate Medical Policy” to “Corporate Reimbursement Policy”. Revision to When Developmental Delay Screening and Testing are not covered: “Preventative counseling for risk factor reduction for developmental delay and the administration of health risk assessment tools are not considered developmental delay screening or testing, and are not covered.” Also, a statement in the Policy Guidelines was revised to read: “Preventative counseling for risk factor reduction and the administration of health risk assessment tools represent other clinical services, and are not considered equivalent to developmental delay screening or testing.” (adn)

2/24/15 CPT code 96127 added to Billing/Coding section. (adn)

12/30/16 Update to Billing/Coding section. Effective January 1, 2017, code 99420 is being deleted and codes 96160 and 96161 are being added. These codes are not applicable for developmental delay screening or testing. (an)

12/29/17 Routine review. No change to policy. (an)

12/31/18 Routine review. Update to Billing/Coding section. Code 96111 deleted. Codes 96112, 96113 added. No change to policy statement. (an)

1/14/20 Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement. (an)

12/31/20 Routine policy review. Medical Director approved 12/2020. No changes to policy statement. (eel)

4/20/21 Policy format update. No changes to policy statement.  (eel) 

12/30/21 Routine policy review. Medical Director approved. (eel)

12/31/2022 Routine policy review. Minor revisions only. (ckb)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.

The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA) has designated certain developmental and autism screening services as preventive benefits and available with no cost sharing when provided by an in-network provider for members of non-grandfathered plans. Check the Member's Benefit Booklet for details on these preventive care benefits.