CPT® Code 96110 is used to report standardized developmental screening performed on children or adolescents, including the interpretation of results and preparation of a report. Developmental screenings assess cognitive, emotional, language, and motor skills to identify potential delays or concerns. The test is typically completed using validated tools such as the
Ages & Stages Questionnaire (ASQ) or other standardized forms, helping providers detect developmental issues early and guide referrals or interventions.
Key Facts About CPT® 96110
Service type: Developmental screening and assessment
Provider type: Physicians, psychologists, nurse practitioners, or qualified healthcare professionals
Patient type: Pediatric patients or adolescents
Time range: Typically 15–30 minutes per standardized test
Medical services included: Yes, administration, scoring, interpretation, and reporting
Common clinical indications:
- Routine pediatric well-child visits
- Suspected developmental delays
- Behavioral or learning concerns
- Follow-up for previously identified developmental issues
- Guidance for early intervention or therapy referrals
When to Use CPT® 96110
CPT 96110 is appropriate when:
- A standardized developmental screening tool is administered to a child or adolescent
- The provider interprets the results and prepares a report for the patient’s medical record
- The test is medically necessary to assess development or guide care
- Documentation includes the screening tool used, results, and clinical interpretation
Examples:
- Administering the Ages & Stages Questionnaire to a 2-year-old and documenting the results
- Screening a preschooler for motor and language delays during a routine visit
- Providing a written interpretation and recommendations for early intervention services
- Assessing behavioral or social-emotional development in a school-aged child
Documentation Requirements
To support CPT 96110 billing, documentation should include:
- Patient identifiers and date of service
- Clinical indication or reason for screening
- Name of standardized screening tool used
- Scores, interpretation, and summary of findings
- Recommendations or follow-up actions
- Provider credentials and signature
Complete documentation ensures compliance, supports reimbursement, and facilitates continuity of care.
Reimbursement and Coding Considerations
- CPT 96110 is reimbursed when medically necessary and properly documented
- Each screening session should be documented individually
- Can be billed in addition to other E/M services if performed separately
- Proper diagnosis coding should support developmental assessment or concerns
- Verify payer-specific guidelines for pediatric developmental screenings
Accurate coding and thorough documentation help ensure appropriate reimbursement and reduce claim denials.
How OptiMantra Supports Developmental Screening
OptiMantra’s integrated EMR and practice management system streamlines documentation and billing for CPT 96110:
With OptiMantra, providers can:
- Document developmental screening results directly in the patient chart
- Record interpretation and include reports in the medical record
- Track screening results over time within the patient’s longitudinal record
- Link screening results to care plans, referrals, and follow-up care
- Support compliant, audit-ready billing codes for developmental assessments
By centralizing developmental screening documentation and billing, OptiMantra helps practices improve efficiency, maintain compliance, and optimize reimbursement.
Try OptiMantra for free here!
Disclaimer: CPT® codes are maintained by the American Medical Association. This guide is for informational purposes only and does not replace official coding guidelines or payer policies.
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