Primary Care Coding Alert

Question: A mother brings in her son because he is having problems concentrating in class. The family physician performs an evaluation and orders tests. How should I code for the concentration difficulty without labeling the child with mental disorders, such as attention deficit disorder (ADD)?

California Subscriber

Answer: As long as your FP hasn't made a definitive diagnosis of ADD (such as 314.00, Hyperkinetic syndrome of childhood; attention deficit disorder; without mention of hyperactivity), you may report the signs and symptoms that prompted the visit. During an initial visit for a child whom a teacher or parent suspects of having ADD, FPs often don't make a definitive ADD diagnosis. They usually need to collect information from family, teachers and psychological tests, before and after medication, prior to confirming ADD.

And, you may use a V code, such as V40.0 (Mental and behavioral problems; problems with learning), V40.3 (... other behavioral problems) or V40.9 (... unspecified mental or behavioral problem), as a secondary diagnosis to the child's symptoms. These diagnoses avoid labeling the child with ADD or some other specified mental disorder. ICD-9 designates V40.0, V40.3 and V40.9 as secondary diagnoses, meaning that you shouldn't use these particular V codes as primary diagnoses. When your FP diagnoses ADD, you should assign 314.00 or 314.01 (... with hyperactivity).