Pediatric Coding Alert

Many pediatric coders have scratched their heads trying to figure out if they can use 90862 for the time spent managing patients on psychopharmacological medicationsparticularly, Ritalin. This is a psychiatric CPT code, and the descriptor states that it is for pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy.

Carriers say that this is a psychiatric code, and pediatricians cant use it, says Diane Kirkle, CPC, compliance coordinator for Creighton Medical Associates, the physician health organization that is part of Creighton University in Omaha, NE. Nothing in CPT says you cant use 90862 if youre a pediatrician, she says. Theoretically, any physician can use any CPT code. But if the carriers wont pay, and if they actually have a policy stating this code is reserved for psychiatrists (and psychologists), then it is a waste of your time to use it.

One of the pediatricians in the practice specializes in treating patients with ADHD, and uses either CPT 99212 or 99213, says Kirkle. She doesnt do a comprehensive exam, just a problem-focused one, Kirkle says of the pediatrician. This pediatrician tried using 90862, but EOBs came back saying the code couldnt be used by a non-mental health professional. If a patient requires psychotherapy, she refers them out.

Use E/M Code

A pediatrician cant use 90862, agrees Peter Rappo, MD, FAAP, assistant clinical professor of pediatrics at Harvard University. Those two pages [of psychiatric codes in CPT] are meant for use by psychiatrists, he says. Our chapter [of the AAP] had a conference about mental health issues, with a panel of people from HMOs, adds Rappo, who practices in Brockton, MA. At first, the representative from Blue Cross/Blue Shield said to use 90862, Rappo reports. But then he had to retract it.

You could use an E/M services code for a Ritalin visita visit in which a child comes to get a renewal of the medication, says Rappo. But, he would probably not go so far as to use a 99213. You dont have to do an exam to refill the prescription, he says. But you do need a history, and you do need medical decision-making. So you could use a 99211 or a 99212.

In fact, Rappo doesnt think its practical to bill for these visits at all. If you do, you have to collect a co-pay, he says. This is a little tricky if youre just writing a prescription. Nevertheless, you could use 99211 or 99212, he stresses.

Code Appropriately for Visit

How you bill the visit depends on what services you perform. If the pediatrician simply refills the prescription without seeing the patient, then no office visit can be billed. If the pediatrician sees the patient, and a history, examination, and medical decision-making are undertaken, then it is appropriate to bill an office visit. If the pediatrician has a counseling sessionface-to-facewith the parent, then an office visit can be billed, with the level based on time.

It is also important to choose an accurate ICD-9 code for reporting these visitsto maximize the likelihood of the payer recognizing the medical necessity of the office visit. We hear that a number of practices are having success using the diagnosis code V58.69 (long-term use of high-risk medications) on the office visit.

Note: Some coders still believe that you should use 90862. As one coder noted in the May 1998 issue of PCA in an article about coding for Ritalin visits, it might make sense to use 90862regardless of whether you get reimbursedjust because this is the only way that insurance companies will change their policies (if they will change).