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 [...]