Pediatric Coding Alert

E/M codes will likely be more appropriate for your pediatrician’s services.

Your pediatricians probably see patients for medication monitoring at least a few times a week—but if you’re not coding these correctly, you could be risking thousands of dollars a year in reimbursement.

Myth: Pediatricians should report +90863 (Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services [List separately in addition to the code for primary procedure]) for attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) periodic medication re-evaluations. You can use this as an add-on code to any other service, including your E/M visits (99201-99215).

Reality: Since pediatricians may report evaluation and management services (E/M), there is no need for them to claim medication management with +90863 when they perform these services. Instead, pediatricians should use the appropriate E/M codes to denote the medication management services that they perform.

Code +90863 was established to denote instances when medication management is provided by prescribing psychologists or other mental health non-medical practitioners who are licensed by their state to prescribe but are not qualified to bill evaluation and management services. In such situations, code +90863 would be reported in addition to one of the psychotherapy codes, such as 90832, 90834 or 90837.

E/M Code Beats Reimbursement Obstacles

You can easily obtain med-check service payment with an E/M code, such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Diagnosis, maintenance, interval checks and reassessment of ADD/ADHD with an established patient can be brief or involved-physician visits. You’ll start out when the pediatrician diagnoses a patient with ADD (314.00, Attention deficit disorder; without mention of hyperactivity) or ADHD (314.01, ... with hyperactivity) by typically looking at a high-level E/M service, such as a 99214 or 99215, particularly if you base your coding on the face-to-face time spent with the patient and/or family counseling and coordinating care.

Tip: Because counseling is usually a predominant component of ADD/ADHD initial diagnosis sessions, anticipate using time to code these encounters, which may take as long as 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. When over 50 percent of the total face-to-face encounter time is spent counseling or coordinating care, the code can be selected based on time alone.

Return visit: After a patient has been diagnosed with ADD/ADHD, he’s going to have interval shorter visits on a scheduled basis. Pin down the appropriate-level office visit code for these interval sessions using these sample guidelines, which could differ based on your documentation:

• 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.

Capture Face-to-Face Monthly Refills: Consider the next round of visits for ADD/ADHD as maintenance. These medication-management services may be based on any face-to-face encounter between the practitioner and the patient.

If the patient comes into the office for an ADD/ADHD medication refill, the physician will typically perform an E/M service with an interval history, questions about the patient’s sleeping and eating habits, and any school or behavior issues. This should all be carefully documented and is typically billable with 99212-99213.

The diagnosis code for these revisits should be V58.69 (Long-term [current] use of other medication) if indeed the patient has been placed on medication for the ADD/ADHD. This code applies because the physician is seeing the patient at that point not because of the ADD/ADHD but more for how the medication is affecting the patient’s body. The chief complaint should be something along the lines of, “Patient presents today for a recheck on the effects of their medication.”