Pediatric Coding Alert

We'll show you which disorder-related services warrant separate reporting

When a patient comes in for a yearly physical and the encounter involves ADD/ADHD, you should sometimes code the problem portion. Our expert gives you CPT recommendations on which activities stand on their own.

At a preventive medicine service, you may initially diagnosis ADD/ADHD or address additional diagnoses of the disorder. You should report a separate problem portion when documentation shows that the ADD/ADHD-focused portion is significant and separately identifiable from the preventive medicine service (such as 99393, Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination ...; late childhood [ages 5 through 11 years] or 99394, ... adolescent [age 12 years through 17 years]).

In these cases, report the history, examination and medical decision-making portion that addressed the ADD/ADHD with an office visit code (99212-99215) appended with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). You'll typically select this office visit code based on time spent counseling and coordinating care. Make sure you separately document the problem from the preventive medicine service.

Get CPT Advice on These Activities

To verify whether you should report a problem-oriented service (99212-99215) in addition to a preventive medicine service (99393-99394), look at how much time you spent on the ADD/ADHD visit/re-evaluation. Consider these scenarios:

1. If the child's disorder is well controlled and you just write a prescription, you probably won't have a significant, separate E/M service.

2. Alternatively, if counseling and/or coordination of care dominate the well-controlled ADD/ADHD portion, you may not spend the time necessary to bill the lowest level of physician-patient office visit service (10 minutes for 99212). 

3. But if at a preventive medicine service, you diagnosis a disorder or the ADD/ADHD requires a significant workup or discussion, you should bill both the problem-oriented service and the preventive medicine service. To support the claim, "make sure you document desired goals and the treatment plan, which are all part of the medical decision-making," says Robin Linker, CPC, CPC-H, CCS-P, CPC-P, MCS-P, CHC, chief executive officer of Robin Linker & Associates Inc. in Aurora, Colo. Often physicians code 9921x-25 based on time, "and the medical record fails in documentation detail during audits."

Take This Combo-Claims-Avoiding Tactic

You may have a patient return for a separate visit for ADD/ADHD, rather than addressing it during the preventive medicine service. Consider this option if a patient's insurer does not cover a claim involving both an office visit and preventive medicine service.