20-687 Age Limit Change for Developmental Screening with CPT Code 96110

Date: 09/04/20

Follow the prior authorization requirements for ages 6–20 to ensure your claims process for payment

The Department of Health Care Services clarified the age limit for general developmental screenings using CPT Code 96110. The age limit change differs from information sent to providers on update 20-182, Prop 56 Payments for Developmental Screenings, dated April 30, 2020. The update stated supplemental payments are made for members under age 21 and did not include further requirements.

Claims submitted for payment dated November 10, 2020 and after will be processed based on the age requirements for developmental screenings listed below.

Prior authorization and age limits

Developmental screening is based on the Bright Futures/American Academy of Pediatrics (AAP) Periodicity Schedule (ages 9, 18 and 30 months) and when medically indicated.

The different age requirements are:

Ages 0 to 5 – Preventive service. No PA is required.
Ages 6 to 20 (New) – Effective November 10, 2020, PA is required to receive payment. This is a change to the original provider update, 20-182.
Ages 21 and older – CPT Code 96110 will be denied. Developmental screenings apply to under age 21 only.

The change is based on Medi-Cal Bulletin 548 dated May 2020, Developmental Screening Policy Clarified: CPT^® Code 96110.

How to bill developmental screenings

The frequency limit for billing general developmental screening for ages 0 to 5:

Twice per year, any provider.
Use CPT code 96110 without modifier KX.

Note: Frequency limits for ages 6 to 20 depend on prior authorization approval.

Autism screening

Screening for autism is based on the Bright Futures/AAP Periodicity Schedule (ages 18 and 24 months) and when medically indicated.

Autism screening does not count toward the developmental screening frequency limit of twice per year and does not qualify for Prop 56 supplemental payment.
Use CPT code 96110 with modifier KX.

Same day screenings

General developmental screening and autism screening are reimbursable when performed on the same day as recommended at 18 months and when medically indicated. When both services are delivered on the same date, add the codes on separate lines:

On one line, add CPT code 96110 without modifier KX (for general developmental screening)
On another line, add CPT code 96110 with modifier KX (for autism screening)

Note: When both screenings are performed on the same day, only the general developmental screening without modifier KX is eligible for Prop 56 supplemental payment.

View prior authorization requirements online

Go to cahealthwellness.com/providers.html. Select Provider Resources > Prior Authorization > Prior Authorization Requirements.

Additional information

The original provider update, 20-182, Prop 56 Payments for Developmental Screenings, dated April 30, 2020 contains other important information on how to qualify for payment, documentation requirements, W-9 and contact information, and submitting a grievance. To view this update, Access Provider News under For Providers at www.cahealthwellness.com and go to April.

If you have questions regarding the information contained in this update, contact California Health & Wellness Plan at
1-877-658-0305.