Pediatric Coding Alert

Question: A child has attention deficit hyperactivity disorder (ADHD). The mother alone comes in to discuss the medications and the child. No exam can be done. How do we charge the  encounter? Whose name -- the mom or child's -- do we charge any allowed service under?

Wisconsin Subscriber

Answer: You can report the established patient visit (99212-99215) based on time under the child's name. CPT allows you to use time as the controlling factor when counseling and/or coordination of care dominates the service. For outpatient coding, time includes face-to-face time between the patient and/or family member. Documentation must include the encounter's total face-to-face time, the counseling time, and a brief counseling summary.

Time-based coding does not require the encounter to meet any of the visit's otherwise required key components. Established patient office visits that are not comprised mainly of counseling and/or coordination of care would have to meet or exceed two of the level's history, examination, or medical decision making requirements. Since time-based coding does not require an exam, you can use time-based coding when the patient is not present. You choose the office visit code based on the visit's documented total face-to-face time. For instance, you would use 99214 (Office or other outpatient visit for the evaluation and management of an established patient ... Physicians typically spend 25 minutes with the patient and/or family) for a visit in which the pediatrician documents that he spent 25 minutes discussing the child's medications and recent behavior with the mother.

Since the counseling addresses the child's needs and problems, rather than how the problem affects the mother, you would report the office visit code under the child's name. Medicare usually does not pay for visits that do not involve face-to-face contact between the patient and physician. This patient present requirement may have led you to assume that there was no coding alternative for these cases, but according to CPT there is.

Make sure to include a counseling V code (such as V61.20, Counseling for parent-child problem, unspecified, which includes "Concern about behavior of child") and the ADHD diagnosis (314.01). This ICD-9 codes combo explains why the patient's condition was being treated without his presence.