Question
I have recently opened a private practice and am learning about coding for insurance. At my previous employer's clinic, we routinely used the CPT code of 96111 for extended developmental/in-depth testing for speech and language evaluations. Yet, I find no
Answer
The official CPT descriptor for 96111 is: Developmental testing, extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments, eg, Bayley Scales of Infant Development) with interpretation and report
The descriptor is found on the ASHA Web site at: www.asha.org/practice/reimbursement/coding Scroll down to "Medicare CPT Coding Rules."
This code is within the Medicare scope of coverage for speech-language pathology services as evidenced in every region that has developed Medicare SLP Local Coverage Determinations (LCDs). While many private health plans adopt various Medicare coverage determinations, some may limit coverage of speech-language evaluations to 92506 only. Medicare has no formal restriction on billing 92506 and 96111 for the same patient, but it is the SLP's judgment that determines if both evaluations should be billed. Whenever billing for 96111, one should fully document the need for additional information that focuses on developmental aspects - - an evaluation that extends beyond the scope of 92506 (Evaluation of speech, language, voice, communication, and/or auditory processing). Note that severely disabled children can qualify for Medicare coverage.
Regarding a "pragmatic/social impairment" ASHA recommends ICD-9 code 784.69, under Other symbolic dysfunction. The disorder should not be termed a pragmatic/social impairment, but a pragmatic language disorder. Autism or encephalopathy can be secondary diagnoses determined by a physician. In your case, encephalopathy, as coded by the physician, should be included in the claim. The primary diagnosis is what you are treating; secondary diagnoses cause or contribute to the disorder you are treating.
Mark Kander, MHA, is the director of health care regulatory analysis in the Health Care Economics & Advocacy Team of the American Speech-Language-Hearing Association (ASHA). Kander assists members with a wide variety of problems encountered in the third party claims process and reviews and comments on draft documents circulated by the Medicare central office as well as local carriers and intermediaries (being transitioned into Medicare Administrative Contractors or MACs).