Pediatric Coding Alert

Ethically boost assessment visits by $61 when you find this documentation

You can capture the initial service and ongoing visits for attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD), if you code based on this coding continuum of care.

Diagnosis, maintenance, interval checks and reassessment of ADD/ADHD can be nurse-only, brief, or involved-physician visits. Here's your guide to keep the visit types straight and to avoid overlooking ethically deserved payments for these time-consuming encounters.

Code Diagnosis Visit as 99215 or 99244

When the pediatrician diagnoses a patient with ADD (314.00, Attention deficit disorder; without mention of hyperactivity) or ADHD (314.01, ... with hyperactivity), you're going to be looking at a high-level E/M service. "You're probably going to be at 99215 (Office visit for the evaluation and management of an established patient ... physicians typically spend 40 minutes face-to-face with the patient and/or family), based on time," says Richard Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. Counseling and/or coordination of care must comprise the majority of the face-to-face encounter to use time as the controlling factor when selecting this high-level of E/M service.

Tip: Because counseling is usually a predominant component of ADD/ADHD initial diagnosis sessions, anticipate using time to code these encounters, which usually take an hour. Encourage the physician to document the counseling session's content, the total face-to-face time spent, and the time devoted to counseling/coordinating care related to the ADD/ADHD disorder.

Don't overlook: If a school nurse or teacher asked for the pediatrician's opinion on the child, and the physician sends a report to the requesting source, you can report the visit as a consultation if the physician performs and documents the other requirements of this service. "These codes pay significantly more than a comparable office visit," says Stephen R. Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Health Care.

Having documentation that shows a counseling-based session of an hour, the time pediatricians usually spend on an ADD/ADHD initial assessment session, can add more than $60 to payment for the first diagnosis session. So if documentation supports a counseling-dominated consultation lasting one hour, you can report 99244 (Office
consultation for a new or established patient ... physicians typically spend 60 minutes face-to-face with the patient and/or family), which has a time allotment of an hour.

The 2007 Medicare Physician Fee Schedule pays 99215 a national rate of $129.60 (3.42 transitional non-facility total relative value units) compared to $191 for 99244 (5.04 RVUs). That equates to a difference of $61.40. Before choosing a consultation code for the visit, make sure you meet the service's requirements (see November 2006 Pediatric Coding Alert "Before You Code Another Consult, Look for These New Criteria").

Report Mid-Level, Testing for Return Visits

After a patient has been diagnosed with ADD/ADHD, he's going to have interval brief visits on a scheduled basis with a pediatrician or nonphysician practitioner, such as a nurse practitioner. Pin down the appropriate- level office visit code for these interval sessions using this guide:

• 99212 -- a brief visit with medication refill

• 99213 -- a brief re-evaluation and medication refill

• 99214 -- a more extensive visit for interval concerns/parental concerns and medication adjustment or refill.

Revenue opportunity: The return visit may include a Vanderbilt ADHD Rating Scale evaluation to assess the patient's progress. You should report this testing with 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report]). Although CPT does not require you to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the associated E/M code when reporting 9921x with standardized testing, some insurers may require this.

Capture Monthly Refills With 2 Options

Consider the next round of visits for ADD/ADHD as maintenance. Code these medication-management services based on any face-to-face encounter between the nurse and the patient.

Option 1: If the patient comes into the office for an ADD/ADHD medication refill, report a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of the physician ... typically, 5 minutes are spent performing or supervising these services) incident-to the on-duty physician.

During monthly visits for medication renewal, the nurse takes "an interval history with questions about the patient's sleeping and eating habits and any school or behavior issues," Tuck says. This medically necessary service must be carefully documented.

Option 2: You may consider using 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy), which is a well-paid code for medication management. Because 90862 is in CPT's psychiatry section, insurers may have mental-health carve outs that restrict coverage of such codes to mental-health providers, says Robin Linker, CPC, CPC-H, CCS-P, CPC-P, MCS-P, CHC, chief executive officer of Robin Linker & Associates Inc. in Aurora, Colo.

Do this: Couple 90862 or 99211 with V58.69 (Long-term [current] use of other medications; high-risk medications), Linker says. The V code describes an encounter for medical management, which is why the patient requires these services.

Use 99371-99373 When MD Makes Call

Finally, remember that you may code for physician phone management of an ADD/ADHD patient, which may occur at any time during the patient's treatment, using 99371-99373 (Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other healthcare professionals [e.g. nurses, therapists, social workers, nutritionists, physicians, pharmacists] ...).

For instance, if the child has a new problem at school and the pediatrician calls the school nurse to discuss medical instructions, you may report 99372 (... intermediate [e.g., to provide advice to an established patient on a new problem, to initiate therapy that can be handled by telephone, to discuss test results in detail, to coordinate medical management of a new problem in an established patient, to discuss and evaluate new information and details, or to initiate new plan of care]).

Beware: Because E/M services include a small amount of pre- and post-visit work, reserve 99371-99373 for calls outside an office visit's bundle. If a call is directly related to a visit follow-up, such as calling with test results after 96110, you should not separately report a telephone call.