Pediatric Coding Alert

Many private payers have mental-health restrictions for their managed care plans. They may refuse to reimburse pediatricians for mental disorders (diagnosis codes 290-319), saying that these conditions can only be treated by a mental-health professional. Although this it not true in scope-of-practice or CPT terms, it helps payers control use. You can facilitate payment by billing the most appropriate code, and, if the payer refuses to pay, collecting from the parent.
 
Fussy baby: The "fussy baby" diagnosis is the least troublesome, partly because there is little question of an infant as a mental-health patient, notes Carel Martin, CPC, biller for the Cle Elum Family Medicine Center in Cle Elum, Wash. "We assume a fussy baby isn't having a behavioral problem," she says. "We use abdominal pain because usually what a fussy baby has is colic." ICD-9 contains no code for "fussy baby" or for infantile colic. Although not all pediatricians agree that all fussy babies have colic, the ICD-9 index lists 789.00 (Abdominal pain, unspecified site) for infantile colic.
 
Toddler temper tantrums: When the pediatrician spends time discussing how to handle toddler temper tantrums with the parent, use 312.1x (Undersocialized conduct disorder, unaggressive type). This might seem an extreme diagnosis for a toddler, but it is the correct diagnosis for temper tantrums, says Richard H. Tuck, MD, FAAP, founding chairman of the AAP coding and reimbursement committee. "This is a perfect example of the ICD-9 index leading you to the correct diagnosis," he says, noting that the proper way to use ICD-9 is the index, not to hunt through codes. Look under "tantrum" in the index, and it directs you to 312.1. 
 
An older child with attention deficit hyperactivity disorder (ADHD) in its mildest form might have only a mild attention problem that manifests itself as problems in school (313.83, Academic underachievement disorder), Tuck says. At its extreme, however, a clear clinical diagnosis that requires medication calls for an ADHD diagnosis (314.xx, Attention deficit disorder).
 
Pediatric coders should pay attention to 313.x-316, which apply to childhood and adolescence. For example:

 

313.3 (Relationship problems) is for sibling rivalry
 

315.4 (Coordination disorder) is for clumsiness
 

313.82 (Identity disorder) is for adolescents who have, for example, "uncertainty about career choice, sexual orientation, moral values."
  
Other useful V codes include: 
 

V61.0 Family disruption
 

V61.20 Counseling for parent-child problem, unspecified
 

V61.8 Other specified family circumstances
 

V61.9 Unspecified family circumstance
 

V62.3 Other psychosocial circumstances; educational circumstances
 

V62.82 Bereavement, uncomplicated
 

V69.8 Other problems related to lifestyle.

Code the condition found, regardless of whether a payer will pay. "If it is a behavioral problem, you have to code the behavioral problem," Martin says. "Then, if the payer won't cover that diagnosis, bill the parent." Use the most appropriate diagnosis codes for your services, and pursue payment.
 
The Classification of Child and Adolescent Mental Diagnoses in Primary Care from the AAP contains information on behavioral symptoms including the spectrum of normal to problem to disorder. There are diagnostic vignettes and age-specific examples of symptoms. This amplified coding helps support higher levels of E/M coding.

Some pediatricians take an aggressive approach with insurance companies. "Payers who refuse to pay a mental-health diagnosis code should be told that the pediatrician will refer all such cases to subspecialists in the future," says Charles A. Scott, MD, FAAP, of Medford Pediatric and Adolescent Medicine in Medford, N.J. "Send every child with ADHD to a neurologist instead, and see how they like it."
 
Scott also takes issue with the insurance companies' assertions that pediatricians aren't mental-health providers. "That's lack of recognition of what we do," he says. "We are mental-health providers. Every well-child check is a mental-health visit. It's ridiculous for them to separate it out." 

Sometimes payers don't have a problem paying an ADHD diagnosis, but they will not pay for some of the necessary services that go with it for example, telephone calls (99371-99373). "If I know that I will be spending a lot of time on the phone with the school, the psychologist and the parents, I tell the parents up front that I will be charging them for phone time," Tuck says. "I tell them the charges probably won't be reimbursed by their insurance company."
 
Prolonged services without direct patient contact (+99358 for the first hour, and +99359 for each additional 30 minutes) are also useful in ADHD scenarios. "This is a perfect example of when to use an indirect prolonged services code," Tuck says. These codes are for time spent reviewing notes from the teacher, test scores, and talking to the teacher and psychologist after the visit. Use these codes on the same date of service in which the child with ADHD is seen; they are add-on codes, so add +99358 to the E/M, and +99359 to +99358.

If a pediatrician sees a child for another issue, you should not add on the behavioral-problem discussion. This is unethical coding, and the original symptom may not justify the level of service rendered.
 
For example, a pediatrician spends 45 minutes discussing a 12-year-old girl's behavior with the parent. The doctor also examines the child and evaluates acne. Because more than 50 percent of the encounter time is spent on counseling, the visit is 99215. The only diagnosis on the claim form is for acne (706.1, Diseases of sebaceous glands; other acne). If the insurance company requests chart notes to support the E/M level, the claim will probably be denied because only acne was diagnosed, but most of the time was spent counseling for ADHD.
 
Sometimes, however, the line between mental and organic problems is blurred. What appears to be a behavioral problem may be organic. For example, a child may have thyroid problems that mimic ADHD. The pediatrician must code the hyperthyroidism (242.9x, Thyrotoxicosis with or without goiter; thyrotoxicosis without mention of goiter or other cause), once that diagnosis is determined. Until then, code the signs and symptoms, which in this case would be V71.02 (Childhood or adolescent antisocial behavior).