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Pediatric Coding Alert

You Be The Coder - ADD/ADHD Evaluation and Testing

Published on Wed Feb 11, 2004

Question: When new and established patients come into a pediatrician's office for an attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD) consult, what is the correct coding? Should I use a consult code such as 99241 or 99242 for the first consultation and then an appropriate E/M code for the following visits? May I charge for Conner's scoring in addition to the consult?

Tennessee Subscriber

Answer: As long as the initial visit meets CPT's consultation requirements, you may report the appropriate-level consultation code (99241-99245, Office consultation for a new or established patient ...). To satisfy CPT's consultation requirements (request, review, report), make sure your pediatrician documents who requested the consultation, such as a school nurse or psychologist, and why it is necessary. Documentation should also include your pediatrician's findings and a notation that he sent a written report to the person who requested his opinion.

Counseling often dominates initial ADD/ADHD visits. If counseling takes up 50 percent or more of the face-to-face time spent with the child and/or parents, you may code the consultation based on time. Documentation should include the content of the counseling session, such as instruction on possible therapies and behavioral interventions. To ensure payment for counseling-dominated visits, your pediatrician should note the total time spent (such as 60 minutes) and the counseling time (for instance, 45 minutes). For this counseling-dominated consultation totaling 60 minutes, you should report 99244 (... physicians typically spend 60 minutes face-to-face with the patient and/or family).

You should select the appropriate established patient office visit code (99212-99214, Office or other outpatient visit for the evaluation and management of an established patient ...) based on time for non-referred and subsequent visits. For instance, if a parent, rather than a school counselor, requests your opinion on an established patient, you should report 99212-99214.

When your pediatrician administers a developmental test (CPT 96110 , Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report), such as Conner's, you may separately report the testing. Make sure the medical record contains an evaluation of the questionnaire results. Some payers may require you to append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the  procedure or other service) to the E/M code, for example 99244, to indicate that the consultation is a separately identifiable service from the testing.

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