CMS to reinstate payment for CPT Code 96110

January 05, 2012

We want to thank all of our members who participated in urging the U.S. Centers for Medicare and Medicaid Services (CMS) to reinstate payment for CPT code 96110.   Thanks in large part to your work, CMS has reversed its decision and has now published relative value units (RVUs) for this code.

Source:  AAP Department of Foreign Affairs

As you may recall, last month, the AAP encouraged all Key Contacts and other AAP members to submit public comments to an online docket in response to CMS’ recent decision to stop covering services for CPT code 96110, a code used to bill for essential developmental, behavioral and psychosocial screenings and services. CMS responded to the concerns outlined in these comments by publishing RVUs and thus reinstating payment for 96110

What CMS’ Decision Means for Pediatric Practices

The American Medical Association’s CPT editorial panel recently changed code 96110 in status from a developmental test to a screen. Since Medicare does not pay for screening or preventive services unless authorized under the Medicare statute, CMS had initially determined that the code was ineligible for payment in Medicare. This decision was made during an annual review of all codes published by CMS in December 2011.

However, as a result of effective advocacy from AAP members from across the country, CMS recognized the consequences of such an action and published values for the code by listing its RVUs. This decision allows both Medicaid and plans in the private insurance market to continue using code 96110 even though it is technically not recognized for payment by the Medicare program.

In a recent Informational Bulletin, CMS stated: “We want to be clear that Medicaid and other private payers will be able to continue to use code 96110 even though it is a statutorily non-covered service under Medicare. In addition, many State Medicaid programs rely upon Medicare-published relative value units, including those associated with code 96110. At the request of Medicaid and concerned stakeholders, in the next few weeks Medicare will provide the relative value units for this code...”

Revised payment files to reflect corrections and revisions to the physician update amount will be posted on the Physician Fee Schedule portion of the CMS website in the near future. In the meantime, the payment rate for code 96110 will be based on 0.28 total RVUs (0.27 practice expense and 0.01 malpractice).

What Comes Next and Where to Learn More

While CMS’ decision is indeed a victory for children and pediatricians, there are still challenges to its potential effectiveness. For example, since CMS does not appear to have changed the status of the code itself, some private insurance plans may resist payment for this code, even though CMS has assured that plans in Medicaid and the private market can continue using 96110.

For additional information on this coding change and what it means for pediatric practices, please visit the AAP Department of Federal Affairs member center

website, FederalAdvocacy.aap.org, and stay tuned for the February issue of AAP News, which will provide additional details.

Source:  AAP Department of Foreign Affairs