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Pediatric screening tools and billing rules
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Defines CPT/HCPCS codes, age ranges, frequencies, modifiers, standardized tests, and billing rules for pediatric screenings for Central California Alliance for Health providers.
Policy Summary
Payercentralcaliforniaallianceforhealth
PolicyPediatric screening tools and billing rules
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionBill 96113 only with 96112 and submit all related services on one claim even if rendered on different days.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
multiplescreening categories listed
up to twicedevelopmental/ASD payable frequency
3fluoride max/12 mo (0-5)
12MNT visits/12 mo
annualACE screening (under 21)
Pediatric Screening Coverage Criteria
Pediatric screening criteria
Coverage and billing criteria by screening type.
Developmental screening (CPT 96110): developmental milestone survey with scoring and documentation; ages restricted to 9, 18, 30 months and when medically indicated (ages 0–5). Payable up to twice in a 12-month period. Validated tools: ASQ-3, PEDS, PEDS-DM, SWYC, BDI-ST. A validated screening tool must test all four developmental domains (motor, language, cognitive, social/emotional).
Autism Spectrum Disorder screening (CPT 96110): required at 18 and 24 months. Payable up to twice in a 12-month period. Use M-CHAT. Modifier KX applies. Can be billed same day as developmental screening.
Neuropsychology testing (CPT 96112; add-on +96113): 96112 (test administration, first hour) payable once in a 12‑month period. 96113 is an add-on code (each additional 30 minutes) and must be billed in conjunction with 96112; up to 10 units per day (not to exceed 6 hours). Submit all services on one claim even if rendered on different days. Modifiers: SA, U1, U7, 99. Common instruments: BSID-III, VABS, DAYC.
Behavioral/psychosocial screening (CPT 96127): brief emotional/behavioral assessment (e.g., depression inventory, ADHD screens). No age restriction. Frequency: up to 2 per day. Modifier U1. Standardized tool example: ASQ-SE-2. Use as medically necessary.
ALL of the following
- Substance use screening: G0442 (annual alcohol misuse screening, 15 minutes) — age 11 and up; frequency: 1 per year; modifier U1; standardized instruments: DAST-10/20, AUDIT, AUDIT-C, CRAFFT; when initial brief screen is positive, follow with validated tool (NM-ASSIST, DAST-20, AUDIT).
- Alcohol/drug screening H0049 — age 11 and up; frequency: up to 1 per day; modifier U1.
- Brief intervention H0050 — age 11 and up; frequency: 1 per day per provider; modifier U1; use validated follow-up tools when initial screen is positive.
ALL of the following
- Depression screening positive (G8431): screening documented as positive AND a documented follow-up plan required; age 12 and up; frequency: 1 per year; modifier U1; instruments: PHQ-2, PHQ-9, PHQ-A, BDI, CESD-R, PROMIS.
- Depression screening negative (G8510): screening documented as negative; age 12 and up; frequency: 1 per year; modifier U1; instruments: PHQ-2, PHQ-9, PHQ-A, BDI, CESD-R, PROMIS.
ACE screening (G9920): payable once a year under age 21 (ages 0–20); ages 21–64 payable once in a lifetime. Provider must self-attest to completion of required core training before billing. Modifier U1. Document whether screening performed and result.
Fluoride varnish (CPT 99188): application by qualified personnel for ages 0–5 years. Frequency: up to 3 applications per 12‑month period. Billed with diagnosis codes Z00.129 or Z13.84; FQHCs should bill Z29.2 as secondary on UB-04. Personnel must be legally authorized to apply.
CPT/HCPCS Codes, Ages, and Frequencies
Behavioral, substance, and depression screeningmixedCovered
| 96127 | Brief emotional/behavioral assessment |
| G0442 | Annual alcohol misuse screening, 15 minutes |
| H0049 | Alcohol and/or drug screening |
| H0050 | Alcohol and/or drug services, brief intervention, per 15 minutes |
| G8431 | Depression screening positive with documented follow-up plan |
| G8510 | Depression screening documented as negative |
Nutrition, hearing, lead, fluorideCPTCovered
Developmental screening ages
Recommended ages9, 18, and 30 months (and ages 0–5 when medically indicated)
Payable frequencyPayable up to twice in a 12‑month period
Required tool featuresValidated screening tool that tests all four developmental domains (motor, language, cognitive, social/emotional)
Common testsASQ‑3, PEDS, PEDS‑DM, SWYC, BDI‑ST
ASD screening ages
Recommended ages for ASD screening18 and 24 months
Payable frequencyPayable up to twice in a 12‑month period
Required testM‑CHAT
Billing noteCan be billed same day as developmental screening; modifier KX required
Fluoride varnish frequency
Applicable ages0 to 5 years
Maximum frequencyUp to 3 applications per 12‑month period
CPT code99188 (fluoride varnish application)
Billing/diagnosis guidanceBill with diagnosis Z00.129 or Z13.84; FQHCs bill Z29.2 as secondary on UB‑04
Billing Rules and Provider Requirements
Documentation Required
Behavioral, substance, and depression screening — billing and documentation requirements
Bill behavioral, substance use, and depression screening codes according to the specified frequencies; a positive depression screen (G8431) must be accompanied by documentation of a follow-up plan.
- Behavioral assessment: 96127 — up to 2 per day (modifier U1 as applicable)
- Alcohol misuse screening: G0442 — annual (age 11+)
- Alcohol/drug screening: H0049 — up to 1 per day (age 11+)
- Brief intervention: H0050 — 1 per day per provider (age 11+)
- Depression screening positive: G8431 — requires documented follow-up plan (age 12+, 1 per year); G8510 documents a negative screen
Key Definitions and Code Notes
Developmental Screening (96110)
Code and description96110 — Developmental screening (developmental milestone survey, speech/language delay screen) with scoring and documentation
UsageUsed for developmental and ASD screening per payer table
Documentation requirementScoring and documentation of the screening must be included in the medical record
96113 (add-on)
Code type96113 — Add‑on code for developmental test administration (each additional 30 minutes)
Billing requirementMust be billed in conjunction with 96112 (first hour); 96113 is an add‑on and cannot be billed standalone
Frequency/limitsUp to 10 per day (not to exceed 6 hours)
Claim submission noteSubmit all services on one claim even if rendered on different days
ACE screening
Annual frequency under age 21ACE screening payable once a year for individuals under age 21
CodeG9920
Provider requirementProvider must self‑attest to completion of certified core training before billing
Ages 21–64ACE screening payable once in a lifetime for ages 21–64
Policy Summary
Payercentralcaliforniaallianceforhealth
PolicyPediatric screening tools and billing rules
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionBill 96113 only with 96112 and submit all related services on one claim even if rendered on different days.
SourceLink
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