Pediatric Coding Alert

Keeping track of time spent diagnosing, developing treatment plans and providing follow-up care for patients with attention deficit hyperactivity disorder (ADHD) is crucial to receiving optimal ethical reimbursement for ADHD patient care.

Although payers in the past may have been reluctant to reimburse pediatricians for providing mental-health services, increasingly insurance carriers are paying for pediatricians'ADHD evaluation and management.

But be aware that payers will be looking for hard evidence, such as documentation from screening tools and psychological test results, to support ADHD diagnoses. Indeed, insurance companies tend to group certain diagnoses, such as ADHD, depression, anxiety disorders and other diseases that may have psychiatric as well as medical characteristics, into a "mental-health pool," says PeterRappo, MD, FAAP, a practicing pediatrician and assistant clinical professor of pediatrics at Harvard University School of Medicine.

From the insurers'point of view, they've already aggregated the dollars for the ADHD, Rappo says. "So your fundamental question, before you even start, is how to get the diagnosis code accepted."

Coming up with a definitive diagnosis for ADHD is not always simple. To confirm a diagnosis, the physician may conduct a multidisciplinary assessment, and these materials may take time to collect.

In addition to supplementary materials such as test results from schools or private psychological testing services, the pediatrician may use diagnostic tools such as those included in the child and adolescent edition of the "Diagnostic and Statistical Manual for Primary Care" (DSM-PC), says David Horowitz, MD, FAAP, a practicing pediatrician with Triangle Pediatric Center in Cary, N.C., and chairman of the mental-health committee of the North Carolina Pediatric Society. (See the note on page 11 for other ADHD diagnostic tools.)

Often, the pediatrician cannot confirm the diagnosis during the initial visit, coding consultants advise.

For unconfirmed ADHD, you can report V codes with the appropriate E/M code. Use V40.0 (Mental and behavioral problems; problems with learning), V40.3 (Mental and behavioral problems; other behavioral problems), or V40.9 (Unspecified mental or behavioral problem).

Insurers may not pay when a claim includes only Vcodes for the diagnosis, so don't expect reimbursement. Insurers want a clear diagnosis, but you should also be honest and code for the level of your understanding even if an ADHD diagnosis isn't apparent, Rappo says.

When the pediatrician confirms the attention deficit diagnosis, select codes in the 314 series (Hyperkinetic syndrome of childhood), depending on whether the patient has hyperactivity, advises Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

When the patient has attention deficit disorder (ADD) without hyperactivity, report 314.00 (Attention deficit disorder; without mention of hyperactivity). For patients with ADHD, report 314.01 ( with hyperactivity).

Initial ADHD assessment visits can be time-intensive because of the counseling involved, so pediatricians should be especially diligent about documenting exactly how much time they spend determining the diagnosis and arriving at an appropriate plan of care for ADHD patients.

Usually, ADHD assessments take an hour, Rappo says.

There are various strategies for reporting the pediatrician's diagnostic services. For instance, you can report 99420 (Administration and interpretation of health risk assessment instrument) for screening, but most insurers do not reimburse for this, Rappo says.

To report the time spent with a new patient, pediatricians would likely use new patient codes 99203-99205, depending on the time spent face-to-face with the patient. For established patients who comprise the majority of ADHD patients you would likely report 99215 because these visits take at least 40 minutes, pediatricians confirm.

Because counseling is a predominant component of these sessions, and the pediatrician will likely spend 50 percent or more of the face-to-face time on counseling, he or she must document the content of the counseling session and the total time spent, Falbo emphasizes. Just noting "counseling mother on ADHD behavioral characteristics" is insufficient, she says. You should include specifics, such as instruction on possible therapies and behavioral interventions.

Again, remember that time can be used to determine an E/M level only if counseling takes up 50 percent or more of the face-to-face time spent with the child and/or parents.

Whether you should append modifier -21 (Prolonged evaluation and management services) to the appropriate E/M code or report a prolonged services code depends on how much extra time you spent providing the service.

If you spend an extra 29 minutes or less on the visit, use modifier -21. The problem with this is that few carriers accept the prolonged services modifier, Horowitz says. "It's a good idea, but it doesn't really work."

Instead, you'll stand a better chance of reimbursement by reporting prolonged services codes, even though pediatricians may find it hard to fit long visits into their schedules. For instance, if you spend an extra 30 minutes more than the allotted time in an E/M code for ADHD patient assessment, report the appropriate prolonged services code (99354-99355) for face-to-face patient services, such as counseling, and 99358-99359 for non-face-to-face services, such as reviewing test results and telephone time talking to teachers and counselors.

For prolonged services codes, you must spend more than 30 minutes to use the first code, plus at least 75 minutes of total time to use the second on a given date of service.

For example, if you spend an extra 30 minutes beyond the 40 minutes CPT allots for 99215, you could bill 99215 and 99354.

If the pediatrician has long conversations with teachers and other professionals about the child, he or she can use a non-face-to-face prolonged service code, such as 99358. Additional 30-minute periods warrant 99359. You can also add the total cumulative time that doctors and clinical staff spend reviewing records, such as psychologists'tests, teachers'letters, report cards and achievement tests, for the given date.

Pediatricians are accustomed to reporting consultation codes (99241-99245) when another physician requests advice on patient care, but they may not know what to do when the consultation request comes from a school nurse or psychologist.

CPT specifies that another physician or "other appropriate source" may request a consultation. Pediatricians can do consultations on their own patients, and CPT considers such professionals as a school nurse or psychologist as appropriate sources, Horowitz says.

If a school official requests that a student see his or her pediatrician for an ADHD evaluation, that is sufficient for billing a consultation code, Horowitz explains.

To satisfy the CPT consultation requirements, make sure you've documented who requested the consultation and why it is necessary, Horowitz says. You should also put your consultation notes in writing and send the document to the person who requested it.

Remember the three R's of consultation: request, render services, and report.

Usually, patients return for a second visit for confirmation of an ADHD diagnosis and to receive instruction on plans of care, including medication to control symptoms. For the most part, second visits can be reported with 99213 or 99214. Again, if more than 50 percent of the face-to-face time is spent in counseling, document the total time spent, the time spent counseling, and specifics on counseling content, Falbo says.

For instance, a physician might write "9/15" on the chart to indicate that 15 minutes total were spent with the patient and that nine of those minutes were on counseling or tasks other than examination.

If time is not the predominant factor, you should code based on the appropriateness of the encounter, whether the medical decision-making was low complexity (99213) or moderate complexity (99214) and whether the documentation meets the requirement of two of the three key elements history, exam and medical decision-making, Falbo says.

Once the patient is on Ritalin or another ADHD medication, pediatricians typically schedule additional visits to monitor drug effectiveness and overall progress and refill prescriptions.

In most cases, these visits are relatively short and require low- to moderate-complexity medical decision-making, so 99213 or 99214 would be appropriate. Some physicians, however, report psychiatric code 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy) for medication management visits, Falbo says. But some payers reimburse for this only if a psychiatrist reports it, so you should check with the payers first, she notes. Code 99214 has higher relative value units (RVU) than 90862, so it's a better choice, if you have appropriate documentation to support it, she adds.

Because medications for ADHD are controlled substances, pediatricians cannot phone them in. Parents come in monthly, in most cases, to pick up the prescription. Report diagnosis code V58.69 (Long-term [current] drug use; high-risk medications) for this service, Horowitz says.

You can report 99211 (Established patient office visit ...) for visits to monitor progress and pick up prescriptions because staff check height, weight and document ADHD patients'progress.

Reporting 99211 requires a co-pay, and some physicians might be uncomfortable charging for a visit like this, although it is justified.

Editor's note: To order the child and adolescent version of the "Diagnostic and Statistical Manual for Primary Care (DSM-PC)," call (800) 433-9016. To learn about the American Academy of Pediatrics'(AAP) ADHD tool kit, go to the AAP Web site http://www.aap.org/ and click on "Bookstore." For other ADHD resources, see the National Initiative for Children's Healthcare Quality site, www.nichq.org/resources/toolkit/.