Primary Care Coding Alert

You can capture the initial service and ongoing visits for attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) if you code based on this coding continuum of care.

Diagnosis, maintenance, interval checks and reassessment of ADD/ADHD can be nurse-only, brief, or involved-physician visits. Here's your guide to keep the visit types straight and to avoid overlooking ethically deserved payments for these time-consuming encounters.

When the FP diagnoses a patient with ADD (314.00, Attention deficit disorder; without mention of hyperactivity) or ADHD (314.01, - with hyperactivity), it's a high-level E/M service.

"You-re probably going to be at 99215 (Office or other outpatient visit for the evaluation and management of an established patient - physicians typically spend 40 minutes face-to-face with the patient and/or family), based on time," says Richard Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. Counseling and/or coordination of care must comprise the majority of the face-to-face encounter when you use time as the controlling factor when selecting this high-level of E/M service.

Tip: Because counseling is usually a predominant component of ADD/ADHD initial diagnosis sessions, anticipate using time to code these encounters, which usually take an hour. Encourage the physician to document the counseling session's content, the total face-to-face time spent, and the time devoted to counseling/coordinating care related to the ADD/ADHD disorder.

Don't Overlook Consultation Codes

If a school nurse or teacher asked for the FP's opinion on the child, and the physician sends a report to the requesting source, you can report the visit as a consultation if the physician performs and documents the other requirements of this service. "These codes pay significantly more than a comparable office visit," says Stephen R. Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Health Care.

Having documentation that shows a counseling-based session of an hour, the time FPs usually spend on an ADD/ADHD initial assessment session, can add more payment for the first diagnosis session. So if documentation supports a counseling-dominated consultation lasting one hour, you can report 99244 (Office consultation for a new or established patient - physicians typically spend 60 minutes face-to-face with the patient and/or family), which has a time allotment of an hour.

The Medicare Physician Fee Schedule pays 99215 a national rate of 3.43 transitional non-facility total relative value units compared to 5.06 RVUs for 99244. Before choosing a consultation code for the visit, make sure you meet the service's requirements.

After a patient has been diagnosed with ADD/ADHD, he's going to have interval brief visits on a scheduled basis with an FP or nonphysician practitioner, such as a nurse practitioner. Code these E/M services based on the notes for the encounter. For example, if the visit is only for a medication refill, it is likely a low-level E/M. If the FP meets with concerned parents and the patient for a medication adjustment, the E/M level will be higher.

The return visit may include a Vanderbilt ADHD Rating Scale evaluation to assess the patient's progress. You should report this testing with 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report]).

Although CPT does not require you to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the associated E/M code when reporting 9921x with standardized testing, some insurers may require this.

Consider the next round of visits for ADD/ADHD as maintenance. Code these medication-management services based on any face-to-face encounter between the nurse and the patient.

Option 1: If the patient comes into the office for an ADD/ADHD medication refill, report a nurse visit incident-to the on-duty physician (99211, Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician - typically, 5 minutes are spent performing or supervising these services).

During monthly visits for medication renewal, the nurse takes "an interval history with questions about the patient's sleeping and eating habits and any school or behavior issues," Tuck says. This medically necessary service must be carefully documented.

Option 2: You may consider using 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy), which is a well-paid code for medication management. Because 90862 is in CPT's psychiatry section, insurers may have mental-health carve outs that restrict coverage of such codes to mental-health providers, says Robin Linker, CPC, CPC-H, CCS-P, CPC-P, MCS-P, CHC, chief executive officer of Robin Linker & Associates Inc. in Aurora, Colo.

Do this: Couple 90862 or 99211 with V58.69 (Long-term [current] use of other medications), Linker says. The V code describes an encounter for medical management, which is why the patient requires these services.