Pediatric Coding Alert

Pay attention to payer rules for testing, treatment options.

It's a common problem that seems to be growing. The Centers for Disease Control (CDC) estimates that it affects 10 percent of children between the ages of 4 and17. Attention-deficit/hyperactivity disorder, or ADHD as it is more commonly known, is a controversial disorder, but it is pretty familiar to mostpediatricians.

So, we've prepared this step-by-step guide to the most common diagnostic and procedural codes you'll need when documenting such cases.

The encounter: A mother reports to your pediatrician with her 8-year-old son, concerned about his impulsive behavior. At school, he cannot sit still, he bothers the other students, and he is failing many of his classes. At home, he is also restless and breaks things.

The testing: Your pediatrician suspects that the boy has ADHD. But before your pediatrician can arrive at a diagnosis, he or she must first administer a psychological test, such as the Vanderbilt Assessment Scale, the Child Attention Profile (CAP), or the Behavior Assessment System for Children (BASC).

Typically, according to Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, when your pediatrician administers one or more of these tests, you will code 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument), being sure to check with your payer if additional units or a modifier such as modifier 59 (Distinct procedural service) needs to be appended for any additional tests.

But Mary I. Falbo,  MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania, notes that you should check with your payers concerning their ADHD diagnostic testing coverages. "Aetna," for example, "considers certain services medically necessary for the assessment of ADHD. However, neuropsychological testing is not considered medically necessary for the clinical evaluation of persons with uncomplicated cases of ADHD."

The diagnosis: On the surface, diagnosis coding for ADHD is a relatively straightforward matter of picking the correct code from the F90- code sequence. However, as Holle points out, "Some carriers will consider these mental health codes to be covered under a different insurance umbrella, and some patients will have no coverage or only 50 percent coverage for mental health."

Consequently, Holle suggests using Z79.899 (Other long term (current) drug therapy) as the primary code after the initial visit where your pediatrician has made the diagnosis of ADHD and has placed the patient on medication and when your provider is seeing the patient for rechecks. "Evaluating how the medication is affecting the patient's body and their mind," Holle reminds coders, "is really why the pediatrician is seeing the patient."

For the secondary code, you might choose either F90.0 (Attention-deficit hyperactivity disorder, predominantly inattentive type) or F90.1 (Attention-deficit hyperactivity disorder, predominantly hyperactive type). Typically, though, patients with ADHD exhibit both inattention and hyperactivity, making F90.2 (Attention-deficit hyperactivity disorder, combined type) the most common diagnosis.

Coding alert: If the patient is diagnosed with attention deficit disorder (ADD) without hyperactivity, you should use F98.8 (Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence) rather than F90.8 (Attention-deficit hyperactivity disorder, other type) or F90.9 (Attention-deficit hyperactivity disorder, unspecified type), as both of these codes specifically mention hyperactivity in their descriptors. And even though F98.8 acknowledges that the onset of ADD occurs in childhood or adolescence, the note to the F90-F98 code block specifies that you can use any of the codes in the sequence regardless of the patient's age.

The treatment: For patient reevaluation and medication monitoring, Holle advocates using preventive medicine visits 99391-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual ...) "because all chronic issues have to be discussed," or regular E/M sick visits 99211-99215 (Office or other outpatient visitfor the evaluation and management of an established patient ... ) "if there has to be a change in the medication or if there is an issue with the ADHD diagnosis."

Typically, you would use a level-two visit to refill medications when there is limited history, no exam andjust a refill is required without changes; a level-three visit for a medication refill and a brief reevaluation; and a level-four visit for counseling the patient and/or parent regarding the child's tolerance for the medicationand to readjust and refill medications asneeded.

Falbo voices a note of caution, however, reminding coders once again to follow payer guidelines, especially when it comes to documenting a complete medical history, a patient's family and social history, and a physical examination. Your pediatrician should also evaluate comorbid psychiatric disorders where appropriate and order a laboratory evaluation, including a complete blood count, a liver function test, and a cardiac evaluation and screening, as, according to Falbo, such testing is necessary prior to a patient beginning stimulant medication therapy.