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CPT Code 96112 Explained: Essential Billing Guide for Healthcare Providers

Stanley Efrem

May 9, 2025

The 96112 CPT code can affect your practice's reimbursement success and patient care quality by a lot. The code replaced 96111 in 2019 and has created new opportunities and challenges for healthcare providers.

A complete understanding of the 96112 CPT code description helps ensure proper billing practices. The code covers the first hour of developmental test administration. These tests assess fine and gross motor skills, language, cognitive level, social skills, memory, and executive functions. The 96113 CPT code works as an add-on for each extra 30 minutes of testing. Total testing time can reach up to 150 minutes. Accurate documentation plays a vital role in 96112 CPT code reimbursement - from patient history to test selection and interpretation. The relationship between 96112 and 96113 helps you avoid common billing issues like wrong time documentation and clerical errors.

This piece will show you everything you need to know about implementing, documenting, and billing these developmental testing codes correctly in your healthcare practice.

Understanding CPT Code 96112

The 96112 CPT code plays a vital role in billing developmental assessments for pediatric care. This code emerged in 2019 to replace the old 96111 code and brought more clarity to developmental testing procedures [1].

What is CPT code 96112?

The 96112 CPT code represents a standard billing code that healthcare providers use for developmental test administration. Healthcare providers can report the first hour of complete developmental testing they perform on patients—mostly children—to spot developmental delays or behavioral disorders. This testing offers a well-laid-out way to review various developmental areas and creates the foundations for treatment plans that work.

96112 CPT code description and scope

The American Medical Association's 96112 CPT code description covers developmental test administration. This includes assessment of fine and/or gross motor skills, language capabilities, cognitive level, social functioning, memory, and executive functions [3]. Qualified healthcare professionals must perform this testing with standardized developmental instruments. The service includes interpretation and report [1]. The code aims to really evaluate developmental areas through complete testing rather than simple screening to diagnose children's problems.

Who can administer this code?

These qualified healthcare professionals can administer and bill the 96112 CPT code:

Physicians (including pediatricians, psychiatrists, developmental pediatricians)
Psychologists
Occupational Therapists
Speech-Language Pathologists
Other qualified healthcare professionals with expertise in developmental assessment [4][5]

Each professional must have their state's licensure in their practice field. This ensures they have the training and expertise needed to conduct complete developmental testing.

Difference between 96112 and 96113

The main difference between 96112 and 96113 lies in their time-based use. The 96112 code covers the first hour of developmental testing, while 96113 works as an add-on code for each additional 30 minutes after the original hour [4]. To cite an instance, a two-hour session would need:

One unit of 96112 for the first hour
Two units of 96113 for the second hour [4]

Longer assessments need more units. A three-hour testing session would need one unit of 96112 and four units of 96113. These codes work together to ensure proper payment for complete developmental assessments that often need extra time to review multiple functioning areas properly.

Clinical Applications in Therapy Settings

Developmental testing under the 96112 CPT code helps multiple therapy disciplines get a complete picture of children's developmental needs and challenges.

Use in occupational therapy

Occupational therapists use the 96112 CPT code to review developmental areas such as gross motor, fine motor, cognitive, language, social, and adaptive functioning skills. This code makes collaborative efforts with other healthcare professionals easier and ensures accurate billing and reimbursement. The proper use of this code helps maintain healthcare regulation compliance and boosts patient care quality. Occupational therapists need proper state licensure and must follow documentation requirements to use this code correctly in their practice.

Use in developmental pediatrics

Developmental pediatricians use the CPT code 96112 as a diagnostic tool for children who show signs of developmental delays. The testing helps create specific diagnoses or prognoses that shape treatment planning and answer questions about treatment goals and effectiveness [8]. Medical necessity must back these diagnostic procedures by directly affecting the patient's plan of care. Tests that don't affect treatment planning aren't medically necessary [8]. Early identification of delays through complete developmental testing lets pediatricians start appropriate interventions quickly.

Common assessment tools used

Healthcare providers often use these standardized instruments under the 96112 CPT code description:

Bayley Scales of Infant and Toddler Development - A complete formal assessment that diagnoses developmental delays in children ages 16 days to 42 months
Vineland Adaptive Behavior Scales - Uses semi-structured interviews to measure adaptive behavior and helps diagnose developmental delays or autism if you have patients ages 0-90 years
Development Assessment of Young Children (DAYC) - Gathers information through observation, caregiver interviews, and direct assessment for children from birth to 5 years

Example: Autism spectrum disorder evaluation

The 96112 and 96113 codes work especially well for autism spectrum disorder assessments. A typical case might involve reviewing a child who struggles with social interactions, communication, and shows repetitive behaviors. The clinician might spend 90 minutes giving tests after getting the history and occupational profile. Scoring, interpretation, and report writing takes another 60 minutes. For this 150-minute evaluation, you'd bill one unit of 96112 CPT code for the first 76 minutes and three units of 96113 CPT code for the remaining 74 minutes.

Step-by-Step Process for Administering 96112

A well-laid-out approach to developmental testing will give accurate results and valid billing under the 96112 CPT code. This standardized process helps maintain compliance and delivers high-quality patient care.

1. Get history and consent

The assessment starts with a review of the patient's occupational profile and developmental history. You need to explain the testing purpose to caregivers and get their informed consent. The original step builds rapport and sets clear expectations. Document any concerns about the child's development because this information helps select appropriate tests.

2. Select and administer standardized tests

A review of the history helps choose the right standardized assessment tools based on the child's age and current concerns. The 96112 CPT code description requires standardized developmental instruments to assess areas like fine/gross motor skills, language, cognitive level, social interactions, memory, or executive functions. Face-to-face administration needs careful attention to standardized protocols for valid results.

3. Record observations and interpret results

You should document behavioral observations and raw test results during testing. Score assessments using standardized procedures after administration. Test interpretation converts raw scores to standard scores and compares results with age-appropriate norms. This key step identifies developmental strengths and weaknesses that are the foundations for intervention planning.

4. Communicate findings and set goals

Clear discussions with caregivers should happen once scoring and interpretation finish. These talks need to highlight strengths and areas needing support. The next step is to cooperate with families to create SMART goals based on assessment results. This shared approach lines up interventions with family priorities and the child's needs.

5. Coordinate with caregivers and professionals

The final step involves sharing findings with other healthcare professionals to ensure coordinated care. Make referrals based on assessment outcomes if additional services would help. Note that 96112 and 96113 billing needs documentation of the whole process, including time spent in administration, scoring, interpretation, and its coverage. Good coordination gives the child detailed support in all necessary areas.

Document the complete testing time accurately for 96112 CPT code reimbursement. Report 96113 CPT code for each additional 30 minutes if testing goes beyond one hour, with total testing potentially reaching up to 150 minutes.

Billing, Documentation, and Compliance Tips

Your success with developmental testing reimbursement depends on becoming skilled at billing nuances of the 96112 CPT code. A clear grasp of financial and documentation elements helps you maximize payments while staying compliant.

96112 CPT code reimbursement basics

Medicare reimburses CPT code 96112 at approximately $127.00. This rate changes based on location, provider credentials, and Medicare fee schedule updates [5]. Private insurers use different rate structures, so you need to check specific payer policies before delivering services. The reimbursement rates have steadily declined over the last several years—from $141.02 in 2022 to $126.74 in 2023, and $121.81 in 2024.

Time-based billing and use of 96113

The 96112 CPT code covers the first hour of developmental testing. Sessions lasting beyond 60 minutes need 96113 CPT code billing for each additional 30-minute block [4]. To name just one example, see a 2-hour assessment that needs one unit of 96112 and two units of 96113 [4]. Note that you must provide at least 31 minutes to report any per-hour code [8].

Documentation standards and common errors

Your documentation must include:

Date of service and specific tests administered
Start and stop times of testing sessions
Summary of results and interpretation
Total time spent scoring and interpreting results [5]

Providers often make mistakes with insufficient time documentation, fail to pair 96112 with 96113, and make clerical errors like typos [4].

Modifiers and payer-specific rules

Multiple services on the same day need appropriate modifiers to ensure proper payment. Modifier -59 shows distinct procedural services, while Modifier XE indicates services from separate encounters [4]. Modifiers -22 and -52 exist for unusual procedures but cannot work with time-based codes [9].

Best practices for accurate reporting

Check insurance coverage before providing services since some payers need pre-authorization [4]. Your records should clearly show medical necessity because diagnostic procedures that don't affect treatment plans lack medical necessity [8]. Careful attention to documentation and coding prevents claim denials and supports quality patient care.

Conclusion

A deep understanding of CPT code 96112 will save your practice time, money and help you avoid compliance issues. In this piece, we explored how this developmental testing code works with its 96113 add-on code to capture your patient assessment work accurately. You need to pay close attention to detail to become skilled at using these codes - especially when you have to document testing time, select the right assessment tools, and interpret results.

In spite of that, implementing these codes properly leads to better reimbursement and improved patient outcomes. Your claims will face fewer denials while you provide better quality care if you follow the documentation standards we discussed. This code remains crucial to bill developmental assessments correctly, even though reimbursement rates have gradually decreased over the last several years.

On top of that, different therapy disciplines can use these codes effectively when dealing with developmental concerns. The standardized testing approach gives you diagnostic accuracy and helps improve communication between healthcare professionals involved in a child's care. Learning and applying these coding guidelines correctly benefits everyone - your practice, your patients, and the broader healthcare team that supports each child's development.

FAQs

What does CPT code 96112 cover in developmental testing?

CPT code 96112 covers the first hour of developmental test administration, including assessments of fine and gross motor skills, language, cognitive level, social skills, memory, and executive functions. It also includes interpretation and reporting of the results.

Who can administer and bill for CPT code 96112?

Qualified healthcare professionals with appropriate state licensure can administer and bill for CPT code 96112. This includes physicians (such as pediatricians and psychiatrists), psychologists, occupational therapists, and speech-language pathologists.

How does CPT code 96113 relate to 96112?

CPT code 96113 is an add-on code used in conjunction with 96112. While 96112 covers the first hour of developmental testing, 96113 is billed for each additional 30 minutes of testing beyond the initial hour.

What are some common assessment tools used with CPT code 96112?

Common standardized assessment tools used with CPT code 96112 include the Bayley Scales of Infant and Toddler Development, Vineland Adaptive Behavior Scales, and the Development Assessment of Young Children (DAYC).

What documentation is required when billing CPT code 96112?

When billing CPT code 96112, documentation should include the date of service, specific tests administered, start and stop times of testing sessions, a summary of results and interpretation, and the total time spent scoring and interpreting results. This documentation is crucial for demonstrating medical necessity and ensuring proper reimbursement.