Pediatric Coding Alert

Better method: Bill rechecks with 99212-99215, not CPT 90862

When coding for ADD/ADHD medication-monitoring encounters, you should avoid the temptation 90862 presents and instead opt for the more accurate and easily reimbursed E/M codes.

Pediatricians often complain of denials when they report 90862 for attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) periodic medication re-evaluations. But as one coder discovered, you can collect payment and report your services more appropriately if you instead use 99212-99215.

Psychiatry Code Triggers Denials

When you provide ADD/ADHD medication rechecks, you may be tempted to use 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy). Coding seminar experts recommend that coders report the encounters with 90862 and 314.xx (Hyperkinetic syndrome of childhood), says Candy Rogers, billing manager with a primary-care practice in Richmond, Va. "Most payers, however, deny our claims because these codes are mental-health codes and we are not mental-health providers."

Unfortunately, Rogers isn't the only coder experiencing pharmacologic management reimbursement problems. "None of our third-party payers paid for 90862 because CPT lists the code in the psychiatry section," says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Catholic Healthcare Audit Network in Clayton, Mo.

Important: CPT does not restrict 90862 to mental-health providers, such as psychologists. Pediatricians may also use the pharmacologic management code. But insurers may deny the service based on mental-health carve-outs that the plan incorporates.

E/M Code Beats Reimbursement Obstacles

You can, however, more easily obtain med-check service payment with an E/M code, such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). Physicians who switched to 9921x coding from 90862 report that they receive reimbursement for these follow-up ADD/ADHD visits, Wilkerson says.

Good news: If you use an office-visit code instead of the pharmacologic management code, not only will you ease your payment problems but you will also be coding correctly.

Why: ADD/ADHD rechecks typically involve an E/M component.

90862 Describes Medication Management Only

You should use 90862 only at a visit in which you provide no psychotherapy and no E/M component. If the pediatrician performs these services, you can include the management in the E/M service, Wilkerson says, referring to CPT Assistant summer 1992's instructions.

Bottom line: Because, in most cases, you probably perform some psychotherapy, history, exam and/or medical decision-making, you should report these encounters with the appropriate-level office visit code, not the pharmacologic management code.

A typical ADD/ADHD medication-check encounter usually requires a history and an examination to ensure the patient is eating enough and sleeping well. "A child who is on Ritalin may not exhibit typical weight gain," says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association with five offices in Lake Forest, Calif. Because Ritalin is a stimulant, it can suppress an individual's appetite and interfere with sleep.

That's why pediatricians who manage medication for patients who are in psychotherapy with non-physician colleagues typically check the individual's health prior to writing or renewing a prescription. "To ensure that our patients are not suffering any major adverse reactions to their medications, we monitor weight gain/loss and follow-up with blood work when appropriate," Rogers says.

You should report these follow-up visits with the "appropriate lower-level evaluation and management code," Wilkerson says. For instance, if you perform and document an expanded problem-focused history, expanded problem-focused examination and low-complexity medical decision-making for a patient prior to writing a Ritalin or Concerta prescription, you should use 99213.

Tip: Time-based billing might allow you to report a higher-level visit. "I use 99212-99215 and select the code solely on time," says Richard Lander, MD, FAAP, pediatrician at Essex-Morris Pediatric Group in Livingston, N.J. CPT allows you to bill an E/M code using its time element as the determining factor when counseling and/or coordination of care dominates (takes up more than 50 percent) the encounter.

You may even be able to bill prolonged services (99354-99355, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service ...) for an ADD/ADHD follow-up visit. "If the visit goes beyond 45 minutes, I append modifier 21 (Prolonged evaluation and management services) to 99215 and charge more than the E/M code's usual fee," Lander says.

Stick With 314.xx Regardless of Coverage

You should continue to use diagnosis codes 314.0x (Hyperkinetic syndrome of childhood; attention deficit disorder ...) despite payment problems. "Codes 314.00 (... without mention of hyperactivity) and 314.01 (... with hyperactivity) appropriately describe ADD/ADHD," Wilkerson says.

Some payers are reimbursing practices that bill 9921x with 314.xx. Other insurers have mental-health carve-outs and may restrict payment for claims containing ICD-9 classified mental-health disorder diagnosis codes, such as 314.00 and 314.01. In these cases, you may bill the patient for a noncovered service.

You may also want to consider contacting organizations, such as the American Academy of Pediatrics or your state insurance commissioner, to lobby for primary-care mental-health coverage in healthcare plan designs.