Pediatric Coding Alert

Its a very common scenario: A child is referred to you by the school for behavioral problems, and you are asked to do an evaluation for ADHD. This is a time-consuming assessment. How should you go about getting reimbursed?

Refer Out to Specialist

Referring out is a common solution. Anything that has to do with ADHD, we refer to the pediatric neurologist, says Mark Rafuls, practice manager for Tender Care Pediatrics, a three-pediatrician practice in Miami, FL.

Many pediatric practices gave us the same answer, apparently feeling that the time involved isnt worth the meager compensation they normally get for a third-level office visit.

But it doesnt have to be just a third-level visit. Sandra Bonney, office manager for Pediatric Associates of Alexander City, a four-pediatrician, one-nurse practitioner practice in Alexander City, AL, has come up with an excellent solution to ADHD evaluation problems.

Prolonged Services Codes

One of the doctors has a special interest in ADHD, Bonney explains. It takes one and a half hours to do the ADHD workup. So we started out billing an office visit, using the prolonged services codes (99354-99355) with it. Bonney billed a CPT 99213 for the office visit, and a 99354 for added time the physician spent with the patient that was more than 30 minutes over the normal amount of time spent on an E/M visit of that level.

It is important to note that the doctor documented his time carefully. Code 99354 is for prolonged services, first hour, and can be used for time spent with the patient that exceeds 30 minutes beyond the normal visit time. Taking the example above, CPT states that a 99213-level visit usually takes about 15 minutes. If the physician was with the patient for an hour for the ADHD evaluation, the practice could bill the 99213, plus the 99354. (See related story on billing for prolonged services on page 23.)

Note: The first 15 minutes are allotted to the 99213 code, the next half hour of prolonged service is included in the 99213, according to CPT guidelines. And 99354 can be used for anything beyond 30 minutes up to the full hour. For every half hour beyond the first hour, the practice could code 99355.

But, as so often happens, an insurance company made this coding scenariowhich was technically correctimpossible. Blue Cross of Alabama said we were using two of the same services, says Bonney. They said it was unbundling, and they bundled it. In other words, they would only pay for the 99213.

Code to Higher Level E/M

So Bonneys solution is to upcode the office visit portion to a 99215. Everything the doctor does qualifies it as a comprehensive visit, she says. We now realize the correct way to code these evaluations is to use 99215 and then add the prolonged services codes. Together, these codes come closer to reimbursing the time outlay for the evaluation. Blue Cross still calls it unbundling, and still bundles it back. They will not acknowledge the prolonged services, Bonney says. But they are paying for the 99215. Bonney still doesnt feel this is totally fair, because the doctor did spend the extra time. And if he saw six patients at 99213 during that time, hed make more money than for the single 99215, she notes. But still, this way, [by being paid for the 99215] the doctors feel they are recouping part of their time.

Correct Diagnosis Coding

Do not use the ICD-9 code for ADHD (314.00 or 314.01) for these evaluations, our sources recommend. We wouldnt label a child with ADHD until we got a full official evaluation from the psychologist, says Carolyn Higgins, insurance clerk for Farmville Pediatrics of Farmville, VA. It goes into their permanent medical record, once you file it with an insurance company, she says. You never want to bill out ADHD to an insurance company until its known for sure.

What diagnosis code should you use for ADHD evaluations? Learning problems (V40.0) or behavior problems (V40.3 or V40.9) are the most appropriate, our sources say. However, these are V codes, and some insurance companies dont pay them.

In general, you should ask the parents to pay in advance, recommends Tom Kent, CMM, practice management advisor and featured seminar leader for Maryland-based McVey Associates. Dont be a wimp on this service, says Kent. It represents too much time. Parents are tearing their hair out with these kids, and they will pay. Kent advises that you explain the whole sequence of visits and the associated costs to the parent in advance.

Post-diagnosis

Once the child is diagnosed with ADHD and under treatment, the pediatrician will examine the patient and review status at regular intervals. Some insurance companies will not pay for these visits using the diagnosis of ADHD, because it is a mental disorder. Kent has had good success using V58.69 (supervision of high-risk medication management) either alone, or with the ADHD diagnosis as a secondary diagnosis.

Usually, says Higgins, the mother calls saying the school wants her child evaluated for ADHD. The pediatrician calls the mom back and asks what she thinks is going on, says Higgins. Then, the child comes in for the initial evaluation. Often, there is a lot that can be done about problem behavior without using the ADHD label or Ritalin, says Higgins. We can try the award system, the office manager says. If a definitive evaluation is needed, the child is referred to a psychologist.

On an added note, like many insurance companies, Blue Cross of Alabama has different ways to pay for ADHD depending on what type of provider sees the child. Here are their coverage rules:

(1) The plan has a network for expanded psychiatric services, and if the child goes to someone in that network, there is no charge to the patient. If the child goes out of the network, there is no reimbursement at all. Pediatricians are not in the network, which is limited to mental health professionals. So if the diagnosis codes are under mental disorders, we cant treat these patients for these conditions, says Bonney. (2) The plan provides no coverage for psychiatric treatment, but allows the primary care pediatrician to do it. (3) The plan allows the pediatrician to treat the psychiatric problem, but the parent must pay an extra deductible. Obviously, these options dont kick in until you are already working with an ADHD diagnosis.