Medicare Compliance & Reimbursement

Question: What codes should we use for attention deficit disorder (ADD)/attention-deficit hyperactivity disorder (ADHD) medication follow-ups? We used an evaluation and management (E/M) code and the claim was denied; however, using a preventive medicine code doesn’t seem appropriate. What would you suggest?

Codify Subscriber

Answer: When the follow-up just involves medication management, 99401-99404 (Preventive medicine counseling and/ or risk factor reduction intervention(s) provided to an individual (separate procedure) …) are not appropriate. That’s because the codes “are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment … and should address such issues as family problems, diet and exercise, substance use, sexual practices, injury prevention [and] dental health …” according to CPT^®. Instead, for an established patient, an E/M code from 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) is more appropriate than a preventive medicine E/M for medication management. In the case of ADD/ ADHD medication management, it’s necessary, given that follow-up appointments generally involve some level of examination and/or history.

However, the issue may be the E/M level you submitted or the documentation you use to justify it. If counseling took up more than half of the visit, for example, you may be able to bill the E/M by time, but you must document what the clinician discussed with the patient or the patient’s family member(s) in detail. Just saying that the practitioner counseled the patient is not enough.

Plus: If billing using E/M elements is more appropriate, then remember that though prescription drug management is listed as a clinical example of moderate medical decision making (MDM), you may not be able to bill for a higher-level E/M. Depending on the elements you choose to determine the E/M level, the exam or history the physician performs — along with the medication management — will probably lower the overall E/M level.

Resource: The Centers for Medicare & Medicaid Services (CMS) offers insight with great examples and tables at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf.