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6.3.19 Developmental and Neurological Assessment and Testing
The following types of developmental and neurological assessment and testing are benefits of Texas Medicaid when medically necessary:
• Assessment of aphasia (procedure code 96105)
•Developmental screening when performed outside of a Texas Health Steps (THSteps) medical checkup (procedure code 96110)
•Developmental testing (procedure code 96111)
•Neurobehavioral testing (procedure code 96116)
The physician must maintain documentation of medical necessity in the client's medical record. Retrospective review may be performed to ensure that the documentation supports the medical necessity of the service. The following information is required at least every six months to establish medical necessity:
•The physician's prescription that includes a description of the specific service being prescribed
•The treatment plan that includes a copy of the current evaluation and documented age of the child at the time of the evaluation
Reevaluations are a benefit of Texas Medicaid only to address a clinical need, to provide the documentation needed to measure a client's status over time, and to direct the plan of care.
Procedure codes 96105, 96110, 96111, and 96116 are used to report medically necessary developmental and neurological assessment and testing. Reimbursement of developmental and neurological assessment and testing is limited by National Correct Coding Initiative (NCCI) guidelines.
Administration of the Mini-Mental State Exam (MMSE) is considered part of an E/M service and will not be reimbursed separately.
Prior authorization is not required for aphasia assessment, developmental screening, developmental testing, and neurobehavioral status exam.
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