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Pediatric Coding Alert

Time Is of the Essence in ADD Evaluations

Published on Mon Jul 01, 2002

Four options exist to reap full reimbursement for the time you spend on evaluation and follow-up care of attention deficit disorder (ADD).

"Very rarely are you going to diagnose ADD at the first visit," says Victoria Jackson, CEO of Southern Orange County Pediatric Associates and owner of Omni Management, which provides practice management for 15 medical offices in the Los Angeles area.

Code Visits as E/M Office Visit

Students often come in for assessment after school officials or other agencies suggest that ADD might be causing behavioral or learning problems they have observed in the child. Code this initial assessment as an E/M visit using the 99212-99215 office visit series, says Wendy Walker, CPC, CPCH, certified professional coder at East Petersburg, Pa.-based Central Penn Management Group, a coding and billing facility serving 18 physician offices.

The first visit typically includes a lot of time spent on determining "the differential diagnosis, a diagnostic plan and potential treatment options," says Richard H. Tuck, MD, FAAP, chairman of the American Academy of Pediatrics' task force on reimbursement and pediatrician at PrimeCare of Southeastern Ohio in Zanesville. Therefore, coders can use an E/M visit's time component and, potentially, other codes.

For example, if the physician spends 30 minutes with the patient, with half of that spent on counseling, code the visit as CPT 99214 ( physicians typically spend 25 minutes face-to-face with the patient and/or family), Walker says. Sometimes evaluations take longer and can be coded 99215 ( physicians typically spend 40 minutes face-to-face with the patient and/or family). In the latter case, the visit must be at least 40 minutes with half the time spent counseling. Documentation of time spent is critical.

The patient usually returns for a second visit, bringing back assessment tools completed by parents and teachers and other information that aid the physician in diagnosing the problem. The pediatrician may also spend time counseling on ADD, its effects, treatment and impact on schooling.

Although these follow-up visits often take less time than the first meeting, they typically meet the requirements for 99213, Walker says. Jackson suggests coding either 99213 or 99214. "The medical-complexity level is certainly there" to justify those codes, Jackson says. Because the physician usually spends a lot of time counseling at this appointment, you will probably use the E/M visit's time component to determine the appropriate code.

Reporting a Consultation May Be Justified

If another physician or other appropriate source, such as a school nurse or psychologist, requests an opinion regarding a child's ADD, consider coding the initial encounter as an E/M office consultation under the 99241-99245 series (Office consultation for a new or established patient).

Jackson recommends this method and explains that in California, physicians often perform consultations at the request of school psychologists.

Modifier -21 Captures Extra 29 Minutes or Less

Time spent beyond the typical amount for an E/M visit or consultation may be captured with the prolonged services modifier -21 (Prolonged evaluation and management services), Jackson says. If you spend an extra 29 minutes or less on the visit, you should use modifier -21, Tuck recommends.

For example, say the pediatrician performs a level-five office visit (99215 physicians typically spend 40 minutes) and spends an extra 20 minutes counseling for a total of 60 minutes. You could report 99215-21. This time represents 20 minutes more than the 40 minutes allowed for the 99215 visit, but 10 minutes less than the 30 minutes required for a prolonged service code.

Prolonged Service Codes May Be Warranted

Prolonged services codes encompass a family of codes, both of which may be appropriate for ADD coding: Two require face-to-face time:

  • +99354 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (list separately in addition to code for office or other outpatient evaluation and management service)

  • +99355 each additional 30 minutes (list separately in addition to code for prolonged physician service).



    Another set captures non-face-to-face time:

  • +99358 Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (e.g., review of extensive records and tests, communication with other professionals and/or the patient/family); first hour (list separately in addition to code[s] for other physician service[s] and/or inpatient or outpatient evaluation and management service)

  • +99359 each additional 30 minutes (list separately in addition to code for prolonged physician service).



    Note: For an easy reference grid to prolonged services codes, see box on right.

    "If you invest an extra 30 minutes more than the time allotted in the E/M code, you may use a prolonged services code," Tuck suggests. To use the prolonged services codes, you must spend over 30 minutes to use the first code, plus at least 75 minutes of total time to use the second on a given date of service.

    For example, in the above 99215 example, if you spend an extra 30 minutes beyond the 40 minutes CPT allots for 99215, you could bill 99215 and +99354. After the first prolonged hour, you should also report +99355 for each additional 30 minutes. Code +99354, which insurers are increasingly recognizing, generally brings higher reimbursement than modifier -21.

    If the pediatrician has long conversations with teachers and other professionals about the child, Jackson suggests using a non-face-to-face prolonged service code, such as +99358. Additional 30-minute periods warrant +99359. You can also add the total cumulative time that doctors and clinical staff spend reviewing records, such as psychologist(s)' tests, teacher(s)' letters, report cards and achievement tests, for the given date.

    Multiple codes help document the time the pediatrician spends and the assessment's complexity, but Jackson says insurers may resist paying for all of the codes. She advises physicians to be persistent, and appeal those that are downcoded or not paid.

    Documentation Is Crucial

    Doctors must carefully document the total time spent with the patient, the time spent counseling, and the subject of the counseling on the discharge summary. For example, Jackson says a physician might use 9/15 on the chart to indicate that 15 minutes total were spent with the patient and that nine of those minutes were on counseling or tasks other than examination.

    "You have to be frugal with your time and be careful to document it on the chart," Jackson says.

    Code Symptoms If ADD Diagnosis Is in Doubt

    When the physician diagnoses ADD, you should select the code based on whether the child has ADD with or without hyperactivity:

  • 314.00 Attention deficit disorder without mention of hyperactivity
  • 314.01 ... with hyperactivity.

    Because the pediatrician usually does not diagnose ADD until the second visit, diagnosis coding often presents a challenge.

    For the first visit, Walker suggests coding the child's symptoms, such as 315.2 (Specific delays in development; other specific learning difficulties) or 312.00 (Undersocialized conduct disorder, aggressive type, unspecified). Doctors should not use "rule out ADD" as the diagnosis because no diagnosis code exists with that name. When physicians put "rule out ADD" on discharge forms, front-office staff may convert it to an ADD diagnosis. Once that diagnosis is attached to a child, "it is hard to get rid of," Walker says. Code V61.49 (Health problems within family; other) can be used when parents want to talk privately with the doctor without the child present.

    Use as many diagnosis codes as apply to document the case's complexity. For example, if a fourth-grade child has ADD with hyperactivity (ADHD) and is reading on a second-grade level, you could code the ADHD with 314.01 and add a secondary diagnosis code of 315.00 (Specific delays in development; reading disorder, unspecified), Jackson says.

    By doing so, "you basically have flagged the insurance company that there are a multitude of problems," Jackson says. Showing this complexity helps the office "justify and defend its coding."

    Be Sure Insurance Covers Evaluation

    ADD evaluations are almost always covered by major health-insurance carriers, just as they cover evaluations for other diseases, says Joseph Luchok, communications manager at the Health Insurance Association of America, which includes among its members nearly 300 private health-insurance companies.

    However, some payers contain mental-health carve-outs that reject coverage for certain diagnoses, such as V40.0 (Mental and behavioral problems; problems with learning) and V40.3 (other behavioral problems). Some also include ADD in these carve-outs.

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