Pediatric Coding Alert

Wonder if you're losing $8 to $90 on office visits for attention deficit hyperactivity disorder (ADHD) rechecks? Make sure you're collecting all your deserved reimbursement with this easy step-by-step guide.

Have you ever reported V58.69 (Long-term [current] use of other medications) on ADHD medication checks only to have payers kick out the claims, which could cost $90 for a 99214? (For payment calculation, see note in step 2.) "In 'Coding

Guidelines,' V58.69 is only a secondary code," explains Jeffrey F. Linzer Sr., MD, MICP, FAAP, FACEP, associate medical director of compliance and business affairs for the division of pediatric emergency medicine, Department of Pediatrics

at Children's Healthcare of Atlanta at Egleston. ICD-9 stipulates that you must first code another diagnosis with V58.69, such as the reason for the medication. You can use V58.69 if the visit's purpose is monitoring the long-term use of [high risk]

medication (not otherwise listed), Linzer says. ICD-9 does not define what a high-risk medication is.

Example: You provide a medication check for possible physical side effects to Ritalin for ADHD. If the visit's purpose is to monitor the Ritalin that the child is taking for ADHD, you would code 314.01 (Attention deficit disorder; with hyperactivity)

as the primary diagnosis and then V58.69 as the secondary diagnosis, Linzer instructs.

When a patient comes in for follow up ADHD checks, you can use time as the controlling factor to select the office visit level when you spend more than 50 percent of the total face-to-face encounter time on counseling and/or coordinating care.

Documentation must indicate the visit's total face-to-face time, the time spent counseling and/or coordinating care, and the topics discussed. "I typically code these visits as 99212s (Office or other outpatient visit for the evaluation and

management of an established patient ... Physicians typically spend 10 minutes face-to-face with the patient and/or family) every three months,"- or 99213s (... Physicians typically spend 15 minutes face-to-face with the patient and/or family),

depending on time, reports Richard Lander, MD, FAAP, a pediatrician at Essex-Morris Pediatric Group in Livingston, N.J.

Reason: Follow-up ADHD visits often involve extensive discussions on school issues, home behavioral problems, diet, and sleep concerns related to medication, says Richard Tuck, MD, FAAP, a pediatrician with PrimeCare of Southeastern

Ohio in Zanesville. The total face-to-face time spent on counseling and coordination of care in these counseling dominated encounters could easily justify 99213. If there is significant appetite or weight loss or sleep concerns, a visit could even be

a 99214 (... Physicians typically spend 25 minutes face-to-face with the patient and/or family), he says.

Coding a 99212 based on medially necessary performed history, examination, and medical decision making, rather than a 99213 -- or a 99214 -- that qualifies for time-based coding, could cut $22 -- or even $52 -- from the claim. Using the 2008

Medicare Physician Fee Schedule, 99212 pays approximately $37* as compared to 99213, which pays almost $60.

For visits involving only physician prescription management, you could consider using 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy) instead of an

office visit. The code is for significant concerns with required medication management when the physician is directly involved in the encounter. The relative update committee database indicates the code has a median intra-service time of 25

minutes face-to-face minutes and 53 minutes total. The fee schedule values 90862 (1.48 RVUs) between 99212 (1.03 RVUs) and 99213 (1.68 RVUs).

Problem: Payers may not recognize 90862 costing you almost $22-$52 as compared to reporting 99212 or 99213. "Using E/M codes would, therefore, be a better alternative," Tuck says.

You could be throwing away approximately $20** (see note for figure calculation) in pay if you write off nurse medication checks. When a nurse who has some additional training in ADHD management takes an interval history, and inquires about

school, home, and sleep behavior, if everything is acceptable at the current dose, 99211 could be appropriate, Tuck says.

**Note: Rate based on 99211's national rate of $19.81 ([0.17 work RVUs x BNA 0.8806 = 0.15 rounded] + [0.06 PE RVUs + 0.01 MP RVUs = 0.52] x 2008 CF 38.0870).

Some physicians opt to do follow-up, such as medication adjustments or refills, by phone. "I require that these children have a yearly complete physical in order for me to continue to prescribe them medications," stresses Nancy Bischof, MD, a

private-practice pediatrician in Lexington, Ky.

Don't assume that at every preventive medicine service for an ADHD patient, you'll also code a problem-oriented visit with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day

of the procedure or other service). "I don't bill for any additional service beyond the physical if the ADHD part of the visit is brief (school going well, no med side effects or change in dose)," Bischof reports. "If there is an extensive discussion of any

problems with changes in meds, I use 99212-99215 (with modifier 25) based on time."