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2025 CPT code 96110

Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument.

This code is for screening purposes only. If further evaluation or testing is indicated based on the screening results, the appropriate codes for those services should be reported separately.

Medical necessity for developmental screening is based on the age of the child, presence of risk factors for developmental delays, or parental/provider concerns about the child's development.

The provider, such as a clinical staff member, administers and scores the standardized instrument, documents the data, and may identify the need for further evaluation.

IMPORTANT:For an emotional/behavioral assessment, use 96127. To report developmental testing, see 96112, 96113.

In simple words: This code represents a developmental screening performed by a healthcare professional using a standardized tool to check a child's development in areas like language, movement, and social skills. The results are documented, and the unit for this code is per standardized instrument.

The provider screens the patient for a developmental disorder using a standardized instrument (such as a recognized form) focused on areas such as developmental milestones and age–appropriate maturity of speech and language. The provider then scores and documents the data.The provider, such as a clinical staff member, uses a standardized instrument (a validated test administered and scored in a consistent manner) to screen the patient. The goal is early identification of patients who need further evaluation of one or more developmental skill areas. Examples include language abilities, cognitive areas, fine and gross motor skills, and social interaction. The provider may use the instrument to determine whether the patient requires any additional work–up for developmental disorders. The unit for this code is per standardized instrument.

Example 1: A 2-year-old patient is screened for developmental delays using the Ages and Stages Questionnaire (ASQ) during a well-child visit., A pediatrician uses the Modified Checklist for Autism in Toddlers (M-CHAT) to screen a 18-month-old child for autism spectrum disorder., A 4-year-old child exhibiting speech delays is screened using the Parents' Evaluation of Developmental Status (PEDS/PEDS-DM) to assess their speech and language development.

Documentation should include the name of the standardized instrument used, the date of administration, the raw scores, and any relevant observations or interpretations made by the provider.

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