Primary Care Coding Alert

A few weeks after students return to school in the fall and again after the winter holidays, many family physician offices see an increase in requests for evaluation of attention deficit disorder (ADD). Some refer the students to specialists for assessment, but others evaluate patients themselves. Proper coding of these visits is essential because the evaluation and follow-up care can take a lot of time.
 
"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.

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 in Central Pennsylvania.
 
The first visit typically includes a lot of time spent counseling on ADD, its effects, treatment and impact on schooling. Therefore, coders can use the time component on an E/M visit.
 
For example, if the physician spends 30 minutes with the patient, with half of that spent counseling, the visit is coded 99214, she says. Sometimes evaluations take longer and can be coded 99215. In that case, the visit must be at least 40 minutes with half the time spent counseling.
 
If another physician or other appropriate source requests an opinion regarding a child's ADD, you may  consider coding the initial encounter as an E/M consultation under the 99241-99245 series (office consultation for a new or established patient).
 
This is the approach recommended by Jackson, who says that, in California, physicians often perform consultations at the request of school psychologists. She says time spent beyond the typical amount for an E/M consultation may be captured with the prolonged services modifier -21 (prolonged evaluation and management services) or its five-digit equivalent, 09921.
 
Another option is to use one of the prolonged services codes such as 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). Code 99354 generally brings higher reimbursement than modifier -21, but the code is less well known and may not be recognized by some carriers. If the physician has long conversations with teachers and other professionals about the child, Jackson suggests using another prolonged services code, such as 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).
 
Multiple codes help document the time spent by the physician and the complexity of the assessment, 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.

Usually the patient will return for a second visit, bringing back assessment tools completed by parents and teachers and other information that will aid the physician in making a diagnosis.
 
Although these follow-up visits often take less time than the first meeting, they typically meet the requirements for a 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 will usually spend much time counseling at this appointment, the coder will likely use the time component of an E/M visit to determine the appropriate code.
 
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 9 of those minutes were on counseling or tasks other than examination.
 
"You have to be frugal with your time and careful to document it on the chart," Jackson says.

Diagnosis coding often presents a challenge. Typically  the ADD diagnosis will not be made until the second visit. So how should the diagnosis be coded at 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 there is no diagnosis code 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 the symptoms if the doctor is at all unsure of the ADD diagnosis," Walker says. "Go back to the doctor. What kind of symptoms is the kid having? There's got to be something we can list."
 
Another diagnosis code, V61.49 (health problems within family; other), can be used when parents want to talk privately with the doctor without the child present.
 
When ADD is diagnosed, use the proper diagnosis code to indicate whether the child has the type of ADD with or without hyperactivity: 314.00 (attention deficit disorder without mention of hyperactivity) or 314.01 (... with hyperactivity). 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."

Evaluations for ADD 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.