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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.25 Developmental and Neurological Assessment and Testing : 9.2.25.3 Developmental Testing

9.2.25.3
Developmental testing (procedure code 96111) is a benefit of Texas Medicaid for clients who are birth through 20 years of age.
Developmental testing must consist of an extended evaluation and include the use of a standardized assessment tool. Developmental testing is medically necessary when there is suspected developmental delay supported by clinical evidence. Developmental testing is only medically indicated when clinical evidence suggests the following:
Procedure code 96111 is limited to two services per rolling year, any provider.
Developmental testing performed when a development delay or a change in the client’s developmental status is not suspected, is not a benefit of Texas Medicaid. Standardized testing (procedure code 96111) is not a benefit when completed to meet day care, Head Start, or school program requirements unless completed during an acute care visit in a clinic setting.
Providers cannot bill the client for developmental testing that is considered developmental screening.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.