New Medi-Cal Policy for Childhood Developmental Screening Reimbursement
April 22, 2020
Effective for dates of service from January 1, 2020, through December 31, 2021, Medi-Cal reimburses providers for developmental screenings with funds from the California Healthcare Research and Prevention Tobacco Tax Act of 2016 (Proposition 56). The Fiscal Year 2019 – 2020 Governor’s budget included funds to be allocated for payments to support developmental screenings for children enrolled in full-scope Medi-Cal coverage under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. The developmental screenings are performed at well-child visits at 9, 18 and 30 months of age, and when medically necessary based on developmental surveillance.
Providers must use a standardized screening tool that meets the criteria set forth by the American Academy of Pediatrics (AAP) and the Centers for Medicare & Medicaid Services (CMS). Billing requires that the completed screen was reviewed, the appropriate tool was used, results were documented and interpreted, results were discussed with the child’s family and/or caregiver and any clinically appropriate actions were documented. This documentation should remain in the beneficiary’s medical record and be available upon request.
Developmental screenings are reimbursed under the fee-for-service (FFS) Medi-Cal program and Managed Care Plans (MCPs) when billed with CPT® code 96110 (developmental screening, with scoring and documentation, per standardized instrument) without the use of modifier KX. For FFS Medi-Cal program providers, developmental screenings are reimbursed up to the max Medi-Cal rate, subject to Medi-Cal policy, in addition to the amount paid for the office visit. For Medi-Cal MCPs, developmental screenings are reimbursed no less than $59.90 in addition to any reimbursement the network provider would normally receive.
For Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Indian Health Services – Memorandum of Agreement (IHS-MOA) 638 clinic providers, developmental screenings for FFS Medi-Cal beneficiaries are reimbursed up to the max Medi-Cal rate, subject to Medi-Cal policy, in addition to the Prospective Payment System (PPS) or All-Inclusive Rate (AIR) reimbursement.
An Erroneous Payment Correction (EPC) will be implemented to reprocess any claims erroneously denied for dates of service on or after January 1, 2020. Providers should continue to bill their claims timely and check for updates on the Medi-Cal website.
Updated manual pages reflecting this change will be released in a future Medi-Cal Update.