Pediatric Coding Alert

Question: I've read about the possible legislation that would disallow insurers from discriminating against mental heath diagnoses when the policy provides mental health (MH) services. Does this mean we'll have an easier time receiving payment for attention deficit disorder (ADD)/ attention deficit hyperactivity disorder (ADHD) services?

Wisconsin Subscriber

Answer: The legislation won't change mental health carve outs. If Congress passes this legislation, plans will still be able to limit mental health services to mental health providers.

Make sure to alert your state American Academy of Pediatrics chapter to insurers that have these restrictions.

For payers, promote the value pediatricians can provide in treating patients with ADD (314.00, Attention deficit disorder of childhood without hyperactivity) or ADHD (314.01, Attention deficit disorder of childhood with hyperactivity). Encourage changes to the plan design by noting that pediatricians are trained and available to manage ADD/ADHD services in a cost-effective manner.

Consider ADD coverage's yearly cost. Suppose you code for a newly diagnosed ADD 7-year-old boy patient in the first year the following 314.00 services:

• an initial diagnosis visit coded based on time as 99215 (Office or other outpatient visit for the E/M of an established patient ...), which the Medicare Physician Fee Schedule assigns 3.43 relative value units

• a total of seven monthly maintenance checks, including four 99212s (1.03 RVUs each x 4 = 4.12) and three 99213s (1.68 RVUs each x 3 = 5.04)

• quarterly reassessments performed and documented as 99214s (3.43 RVUs each x 4 = 13.72).

Annual ADD visits total 26.31 RVUs. The services pay a nominal rate compared to other mental health services with a national rate of about $1,002, using Medicare's 2008 first-half conversion factor of 38.0870.