Pediatric Coding Alert

Attention Deficit Hyperactivity Disorder (ADHD) can take a lot of time, both up-front and in follow up. There are effective ways to code for these appointments, depending on the situation. We talked to Judith Wise, CPC, department manager of pediatrics at West Virginia University Hospital in Morgantown, WV. Here are her recommendations for optimal ADHD coding.

1. Prolonged services for initial workups. Because the workups can take three, four, or five hours, Wise uses the prolonged services codes. For the time the pediatrician spends with the child, she uses 99354 for the first hour, and 99355 for each additional 30 minutes. Much of the time may be spent with a social worker, however, and for that time Wise uses 99358 for the first hour, and 99359 for each additional 30 minutes. Whether the codes are for face-to-face patient contact (99354 and 99355) or without direct patient contact (99358 and 99359), Wise bills under the pediatricians name because he is always there, supervising.

Note: The 99358 and 99359 codes cant be used unless the pediatrician has had some face-to-face contact with the patient, either before or after the social worker (or both before and after).

2. Prolonged services for extensive review of records. A new approach to getting reimbursed for evaluating a childs medical records, which can take 1 to 1 1/2 hours, is to use the prolonged services without face-to-face contact codes (99358 and 99359), explains Wise. We conduct an extensive review of medical records before we do anything else, she says. We spend this extra time with every ADHD child, and we havent been able to get reimbursed for it. So were trying something new by utilizing these prolonged services codes. Although the initial response is promising, its too early for definite results. But if youre not being reimbursed at all, trying this cant hurt.

3. Testing codes. For following up on ADHD patients, Wise usually utilizes the codes for central nervous system assessments. The ones she uses depend on what was done. Here are the four main codes that Wises practice submits for ADHD follow-ups.

Note: All but 96110 are coded per hour, and all require extensive documentation and reports to be placed in the child's chart.

96100 - Psychological testing (includes psychodiagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, e.g. WAIS-R, Rorschach, MMPI) with interpretation and report, per hour.

96110 - Developmental testing; limited (e.g. Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report.

Note: 96110 coding is not determined by time spent with a patient but by what is done during the exam.

CPT 96111 - Developmental testing; extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report, per hour.

96115 - Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgement, e.g. acquired knowledge, attention, memory, visual spatial abilities, language functions, planning) with interpretation and report, per hour.

4. Pharmacologic management code. Wise uses 90862, a psychiatric code for pharmacologic management, including prescription, use, and review of medication. Does it always get reimbursed? No. But if we dont keep billing it we wont get people to change, she believes.

5. Determining the office-visit level. Wise never uses a 99201 or 99211 office visit for a child with ADHD. First of all, Medicaid wont reimburse for it, she says. So you want a level 2 at least. There is no rule-of-thumb for what level to use for these children, Wise explains. Patient A could be doing very well. Patient B might need some testing. You should consider each case individually, or you could be losing a substantial amount of money by undercoding.

6. Frequency of visits. While not strictly a coding question, this issue is closely tied into being adequately reimbursed for treating ADHD patients. How often a child comes in for a prescription -- and how frequently you must bill -- depends on how well the child is doing. And, of course, the more frequently you see the child, the more you are going to raise red flags at the insurance company. We tend to see a patient who is not stable every three to four months, says Wise. For a child whos stable, every six months is fine. The pediatrician sees the patient and writes a Ritalin prescription to last until the childs next appointment -- usually three to six months.

7. The capitation problem. If you have ADHD patients under capitation, you may have a special problem. Hiro T. Huang, MD, a pediatrician in Laurel, MD, asks: Our office deals with quite a few ADHD follow-ups. Many patients are covered under HMOs and we are not being paid for these follow-up services. The HMOs classify these as office visits covered under their regular capitation payments. Some of these visits take more time (30 minutes or more). Are there any codes we can use to help us get more compensation for these visits?

In addition to the earlier codes recommended by Wise, a special recommendation for capitated situations comes from Mark Rafuls, practice manager of Tender Care Pediatrics in Miami, FL. If you have documentation that will support the frequency of seeing these children, negotiate with the HMO for a bill-above, says Rafuls. Dont include it in the capitation amount. These kids will cost you a lot under capitation.

Study Indicates No Evidence of Ritalin Overprescribing There is no evidence that there is any overprescribing of Ritalin for ADHD, or in fact that any widespread misdiagnosis or overdiagnosis has occurred, a study published in the April 8 JAMA reports. The study, done by the Council on Scientific Affairs of the AMA, reviews the use of Ritalin and other stimulants to treat ADHD in children from 1975 through 1997. Ritalin use tripled between 1990 and 1995 alone, but there is little evidence that the prescriptions are not necessary. The study estimates that 3 to 6 percent of the school-aged population may have ADHD. However, the study also warns that pediatricians must be mindful of the risk of abuse and diversion. This means careful paperwork, standardized diagnostic criteria, and, possibly, alternatives for children who have family members with substance abuse problems.