Neurology & Pain Management Coding Alert

Question: How should I code for a child who is inattentive or has trouble focusing without labeling him as ADD (Attention Deficit Disorder)?

Texas Subscriber

Answer: Neurologists often may not make definitive ADD diagnoses during an initial encounter. In that case, code for the child's symptoms, as ICD-9 guidelines instruct. Use codes such as 315.2 (Specific delays in development; other specific learning difficulties) or 312.0x (Disturbance of conduct, not elsewhere classified; undersocialized conduct disorder, aggressive type), depending on your neurologist's documentation.

If, however, your neurologist diagnoses ADD, assign one of two ICD-9 codes, 314.00 (Hyperkinetic syndrome of childhood; attention deficit disorder; without mention of hyperactivity) or 314.01 (- with hyperactiviy), even if it does label the child. You must report the relevant documented diagnosis.

Note: Payers may have different coverage policies for mental-health-related ICD-9 codes, meaning they may have a separate billing and/or payment system for mental-health services.

Beware: Some coders suggest using a V code instead, such as V40.0 (Mental and behavioral problems; problems with learning), V40.3 (... other behavioral problems) or V40.9 (... unspecified mental or behavioral problem). Per the HIPAA mandated ICD-9 Guidelines, effective October 2007, the V40.x codes are considered to be one of the nonspecific V code categories. The guidelines direct that you should limit these codes to those instances when there is no further documentation to permit more precise coding. Otherwise, you should use any sign or symptom or any other reason for visit that is captured in another code. Additionally, these V codes can cause reimbursement problems. Some insurance companies refuse to pay claims containing only a nonspecific V code for the diagnosis. (http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf)

Stick to the rules: Code the condition documented, regardless of whether a payer will pay. A behavioral problem must be coded as a behavioral problem, experts say. If the payer won't cover such a diagnosis, still use the most appropriate diagnosis codes, and pursue payment from parents.

-- Clinical and coding expertise for You Be the Coder and Reader Questions provided by Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.