Pediatric Coding Alert

When a child has a psychosocial problem, depression, or Attention Deficit Hyperactivity Disorder (ADHD), the amount of time the pediatrician spends with the child and parents can be extensive. Most of which is spent on counseling. But if pediatricians want to get paid by managed care, they shouldnt use the psychiatric CPT codes (90804-90899). So how can the pediatrician get reimbursed for these services?

Why Psychiatric Codes are Not the Answer

First of all, it needs to be explained why you cant use the psychiatric codes, which seem to be the most applicable here. Technically, any physician can use any code in CPT, explains Diane Kirkle, CPC, compliance coordinator for Creighton Medical Associates, the physician health organization that is part of Creighton University in Omaha, NE. However, most managed care companies have reserved the psychiatric codes for mental health specialists, and many will only pay those codes for those specialists.

Using the psychiatric codes will guarantee non-payment to most primary care providers, agrees Peter Rappo, MD, FAAP, immediate past chair of the American Academy of Pediatrics (AAP) Committee on Practice and Ambulatory Medicine. Theyre for psychologists and psychiatrists, says Rappo, who practices in Brockton, MA. The reason, he explains, is that managed care companies have separate risk pools for mental and physical coverage. In many cases, the managed care company is already allocating payments for behavioral healthcare in a carve-out, so it confuses the carriers utilization data to have non-behavioral providers (primary care pediatricians) using the psychiatric codes.

Note: A carve-out means that a specific benefit is not covered under the contract between the carrier and the practice, and will be paid separately.

Will Fessenden, billing supervisor for Pediatric Associates of Newark, DE, notes that insurance companies regard pediatricians as primary care providersperiod. If the carrier sees you using a psychiatric code, theyll automatically say youre doing the work of a psychologist or psychiatrist, says Fessenden, who worked in billing for a psychiatric hospital for five years, and who has also worked for an insurance company. You would need a lot of documentation in the chart to use any of these codes, and even if you did, you probably still wouldnt get paid.

Tip: There is one psychiatric code which you can, sometimes, use with success. It is CPT 90862 (pharmacologic management, including prescription, review, and use of medication with no more than minimal medical psychotherapy). This is the code that some insurance companies will let pediatricians use for the regular and periodic Ritalin appointments required for ADHD treatment. However, the RVU for 90862 is 1.38, which is less than the 1.83 for 99214, notes Richard H. Tuck, MD, FAAP, of PrimeCare Pediatrics in Zanesville, OH and a founding member of the RBRVS RUC of the AMA.

Frequently, there are a lot of issues that need to be discussed at these Ritalin appointments, Tuck says. So its not unusual to use 99214 (establised patient visit) or even 99215 (based on time spent counseling) for the appointments. You would be cheating yourself if you billed 90862 instead of 99214. Add to this the fact that 90862 might be a hard code to get reimbursed for, and it becomes clear that the E/M services codes are the most reliable for these visits.

Code Based on Time for E/M Services

The fact is that 18 percent of psychosocial problems are identified in primary care settings, says Rappo. And with 12 to 30 percent of children having psychosocial problems, psychiatric coding questions are going to be fairly common in any pediatric practice. So you need to figure out how to code these problems properly.

If you cant use the psychiatric CPT codes, what codes can you use when providing counseling services? The answer is the E/M services codes: 99201-99215, office or other outpatient services. Levels for these office visits can be based on time, if 50 percent or more of the time with the child and/or parents is spent on counseling. This rule, spelled out in the introduction to the E/M services in CPT, says that time may be the key or controlling factor to qualify for a particular level of E/M services.

This is key to ADHD coding, because this disorder is very time-consuming to treat. Many patients have some behavior problem which calls for an evaluation to see if they have ADHD. And if they dont, other steps need to be taken to treat other behavior problems or refer them to a psychiatrist.

At Londonderry Pediatrics (NH), practice manager Jeannine Bailey, CMA has set up a comprehensive ADHD evaluation program. Here are the four steps she uses:

1. First Visit: Comprehensive exam. The first session is almost always a level 5 office visit, she says. The child comes in with the parent, the pediatrician discusses issues with the parent, and conducts a comprehensive examination of the child, she says. For an established patient, this code is 99215 and comprises 40 minutes; for a new patient, it is 99205 and it comprises a full hour.

2. Second Visit: Testing. The second visit is the Continuous Performance Test, a computerized test which the child can take in 10 minutes. The nurse gives instructions on how to do the test, and then the computer gives feedback, Bailey explains. This visit is often a 99211-99212, because the pediatrician does not usually speak with the family. If there is physician counseling added to this, and the pediatrician spends more than 50 percent of his or her time on counseling, the visit could be upcoded at a higher level to a 99213 (15 minutes) or even a 99214 (25 minutes).

3. Third Visit: Test follow up. At the third visit, all of the results have been processed and the pediatrician discusses them with the parents. The child may need medication, counseling, or both. This visit is almost always a 99213, unless there are complicating factors.

4. Subsequent Visits: Medication checks. At the medication follow-ups, which must be done regularly, the pediatrician checks the patients height and weight and does a brief examination of the child, says Bailey. This visit is almost always a 99212, unless there are complicating factors.

Tip: The pediatrician should be able to treat the child. But if other psychological problems, in addition to ADHD, are causing the behavior problems, the pediatrician would probably refer the child to a mental health professional, recommends Bailey. This highlights one of the problems pediatricians in rural areas have: lack of pediatric psychiatrists. This leaves psychologists and neurologists as referrals. We lose some ADHD patients in the loop, because psychologists cant prescribe medication, and neurologists generally dont do counseling, says Bailey.

Documentation is Critical to Reimbursement

In order to base the E/M level on time it is essential that you document the extent of the counseling performed. Write down what you did and what you talked about, is how Rappo describes this documentation. Nobody knows how a primary care provider is supposed to document counseling. Rappo recommends that you use the following guidelines for psychiatric documentation. Its for psychiatrists, and its probably more than you need, but you cant go wrong if you do this. The psychiatric documentation elements are:

1. Date of session

2. Length of session

3. Notation of patients clinical status with signs,symptoms of patients condition

4. Content of session

5. Therapeutic interventions

6. Patients progress

7. Documentation of need for ongoing therapy
or assessment

8. Documentation of treatment failure or changes

9. Treatment goals and objectives

10. A note for every visit

Also, you need to be prepared to justify what you have done to the managed care company if the claim is rejected, says Joseph Hagan, MD, FAAP, a member of the AAP Committee on Psychosocial Aspects of Child and Family Health. Writing in the August issue of AAP News, Hagan says that you will need to assert that the diagnosis that was made is a significant health problem for your patient and therefore is a covered condition. This can be done via a form letter that has the patients name, date of birth, and insurance number at the top, with check-off boxes for what services were provided under the diagnosis code (parent conference and how long it lasted, face-to-face visit with child and how long it lasted, review of school records, correspondence with school, and an other category). A copy of this form letter goes to the case manager at the insurance company.

Negotiating a Contract for Payment

Sometimes, the problem of reimbursement for psychosocial services is more of a contractual one than a coding one. It is possible to contract with the managed care organization to allow your pediatricians to do, and get paid for, these counseling sessions. Hagan points out that in cases such as divorce adjustment or ADHD management, the brief interventions that pediatricians do are much more cost-effective than referring the child to a mental health service, where the child isnt known, and where at least four visits will be required before the provider can even assess the problem. This message isnt lost on managed care companies. But to make this work, you need to handle it at the negotiation stage, not with each claim that arises.

Also at the negotiation stage, you can remind the managed care company that indeed, some primary care pediatricians do counseling. Point out the difference in your referral patterns compared to those of other primary care providers in your community, Hagan says. For example, if you provide care to most of your patients with ADHD, while other primary care colleagues refer the majority of these patients to mental health professionals, then the difference in your referral pattern might have real financial benefit to the managed care organization.

Yes, there is something cyclical going on here: Pediatricians refer psychosocial problems to mental health providers because they dont think insurance companies will pay them to do it, and insurance companies dont pay pediatricians to do counseling because they view it as the province of psychologists and psychiatrists. But you dont have to be a part of this cycle. If you can demonstrate that the diagnosis is a covered benefit, push to get reimbursed, and improve the services for children who have behavioral problems, you will be winning all around.

The ADHD Carve-Out

Another solution in managed care contracting is to carve out ADHD care. Explain to the managed care company that you have a special interest in treating ADHD patients. Draw up a financial summary (i.e., cost for each visit and total cost) of a typical patients treatment plan for the year and demonstrate that you will be less expensive than the mental health group. You will have to negotiate the package price but you can usually reach an agreement to treat these children.

For those plans which will not negotiate a carve-out, you can make a similar offer to the parents. Thomas Kent, CMM, president of Kent Medical Management in Dunkirk, MD, recommends that in such cases you tell the parents the following: Your insurance requires the ADHD child to be treated at a mental health facility. If you wish to go outside of the insurance I can continue treating your child for this problem. Here is a copy of the likely visits and charges which you will pay directly. This gives the parent full information and allows them to make the choice.

Tip: The office manager can also offer to teach the parent how to fight for full reimbursement from the insurance plan, says Kent.

Diagnosis Codes Can Also be a Problem

The diagnosis codes for children with behavioral or psychiatric problems are tricky: Some insurance companies automatically assume that anything with a diagnosis code from the mental disorders (290-319) section of ICD-9 should be treated by a psychiatric professional. But after doing a complete evaluation, pediatricians usually dont need another professional to tell them whether the child has ADHD. Likewise, if a child is reacting to stress in the home, such as with divorce, the pediatrician doesnt need to refer the child out to find out that there is an adjustment disorder (309.0). If the child has enuresis (307.6), is it always necessary to call in a child psychiatrist?

There is a diagnostic manual which is very helpful to pediatricians. Its called the Diagnostic and Statistical Manual for Primary Care (DSM-PC: Child and Adolescent Version) and it is a collaboration of pediatric, behavioral, and mental health communities, says Rappo. It is based on the principle that psychosocial issues are a part of primary care, and that when physicians treat these, they need to be reimbursed fairly. Rappo calls the DSM-PC a Rosetta Stone which links medical and mental health fields in spite of the carve-outs which are an established part of managed care. (To order the DSM-PC, contact the AAP Department of Marketing and Publications at 800/433-9016.)

Rappo believes that by educating managed care companies, pediatricians can make it easier to get reimbursed for treating psychosocial problems. But this can only be done if pediatricians call mental health disorders what they are. If I code a patient as being depressed, that should be a valid code for reimbursement, says Rappo. You should tell it like it is.

And Bailey agrees. We use whatever diagnosis codes are appropriate for the case, she says. Even if its a V code, we use it, if its appropriate. There are no problems with collecting from managed care, she says. But she adds that she puts every diagnosis code that is appropriate on the claim.

How should you handle diagnosis coding when the patient is referred out for evaluation? Some pediatricians prefer not to diagnosis ADHD and always send suspected cases to a psychologist for the initial evaluation and testing. Once the child is diagnosed, the psychologist will recommend a treatment plan which the pediatrician can then implement and monitor at the three-month interval checks for Ritalin renewal. If the pediatrician has not seen the child for the initial evaluation, some insurance plans will deny the medication monitoring visit if the ADHD diagnosis code is used first. Esther Y. Johnson, MD, FAAP of Dunkirk, MD has had success using V58.69 (long-term [current] use of other medications; high-risk medications). This diagnosis code can be used along with or followed by the ADHD diagnosis code.