Billing Developmental Disorders

Jul 30th, 2026

Developmental disorders are conditions that impair physical, cognitive, language, behavioral, and/or social development and typically begin in childhood. They include disorders such as autism spectrum disorder, intellectual disability, and communication disorders. Services for these disorders focus primarily on improving quality of life and treatment often requires specialized evaluation, therapy, educational support, and long-term management.

Coverage varies significantly between payers but most will require a reasonable expectation of improvement where ongoing therapy is necessary to maintain a certain level of functioning or prevent a deterioration of their level of functioning. For example:

• Medicare
  • Covers medically necessary physician services, psychotherapy, physical therapy (PT), occupational therapy (OT), and speech therapy.
  • Generally does not cover adaptive behavior services (ABS) as a distinct benefit.
• Medicaid
  • Often provides the broadest coverage for children with developmental disorders.
  • Many state Medicaid programs cover ABS, OT, PT, speech therapy, behavioral health services, and caregiver training.
• Commercial Insurance
  • Most plans cover medically necessary evaluations and therapies.
  • ABS coverage varies by state mandates, employer plan design, and medical policy.
  • Prior authorization and documented treatment goals are commonly required.

The following are some services commonly associated with treating an individual with a developmental disorder. The PURPOSE of the encounter/visit is the driving factor in code selection.

Note: Evaluation and Management (E/M) services are not generally reported for a patient with a developmental disorder unless the physician or qualified healthcare professional (QHP) is performing services which require medical decision making. For example,

• See a neurologist to address a seizure disorder
• Visit a primary care provider to treat an illness
• Consult a psychiatrist for psychotherapy along with medication management

Does the patient need to be present for all these services? Generally, yes, they need to be present because the service requires the active participation of the patient. However there are some services which do not have the same requirement such as family adaptive behavior treatment guidance (code 97156) or BHI.

The standards of care for treating developmental disorders is based on the disorder. For example, care for an adult patient with Angelman syndrome should address the following:

• Independence with activities of daily living (ADLs)
• Seizures
• Sleep
• Behavior
• Scoliosis
• Mobility
• Augmentative and assistive communication (AAC) device use and integration
• Weight management

Whereas, care for an individual with a speech disorder is less complex.