Primary Care Coding Alert

Don't let conflicting information on using 90801 and 90862 versus 99214-99215 for ADD/ADHD evaluations rattle your reimbursement. Find out what mental carve-outs mean, if psychiatric codes are right for your family physician (FP), and why knowing your top insurer's local medical review policies (LMRPs) will help get services for mental-health care paid.

Be Aware of Carrier-Imposed 90801/90862 Limitations

 "Although CPT does not restrict code series to certain providers, many insurance companies allow only behavior health providers to use the 90800 (psychiatry) series," says David I. Berland, MD, chairman of the American Academy of Child and Adolescent Psychiatry (AACAP) codes and reimbursement committee and AACAP AMA CPT advisory committee adviser.

For instance, the LMRP for New Jersey's Medicare carrier, Empire Medical Services, limits coverage of the diagnostic interview (90801, Psychiatric diagnostic interview examination) to physicians certified in New Jersey for psychiatric services. So, if an FP diagnoses a New Jersey Medicare patient with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) and bills 90801 for the visit, the carrier will deny the service. In addition, for subsequent ADD/ADHD visits, in which a physician re-evaluates the patient and/or performs medication rechecks, Empire will pay only psychiatrists for 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy).
 
Numerous FPs receive denials for ADD/ADHD evaluations and re-evaluations for reasons similar to Empire's LMRP, which carves out mental-health services, Berland says. "Insurers' policies vary, making research crucial." Therefore, physicians should find out their major payers' policies and make a list of how each of them wants the services billed.

Watch for Plans That Allow E/M Service

Although checking insurers' guidelines may seem time-consuming, your practice's bottom line will definitely benefit from knowing your top 20 percent of payers' mental-health coverage rules. For instance, if the New Jersey coder in the above example made a list of Empire's acceptable billing protocols, she would find out that she should substitute an E/M service, such as an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient) or consultation (99241-99245, Office consultation for a new or established patient), for the initial ADD/ADHD interview procedure, provided her FP meets the codes' required elements.

"FPs absolutely should use the E/M codes," Berland says. For the initial and subsequent visits, he recommends billing based on time. "The physician usually spends more than half the time during these visits discussing the patient's diagnosis and treatment plan," he says. When counseling and/or coordination of care dominates (more than 50 percent) the encounter (face-to-face time in the office or other outpatient setting), CPT states that the physician may consider time as the key factor in selecting the level of E/M service. Because counseling will dominate ADD/ADHD-related visits, Berland recommends reporting 99214 ( physicians typically spend 25 minutes face-to-face with the patient and/or family) or 99215 ( physicians typically spend 40 minutes face-to-face with the patient and/or family) for the initial visit, and 99212 ( physicians typically spend 10 minutes face-to-face with the patient and/or family) or 99213 ( physicians typically spend 15 minutes face-to-face with the patient and/or family) for follow-up services.

300-316 May Trigger Denials

Regardless of procedural coding, mental-health services carve-outs may cause additional reimbursement problems. "Unfortunately, many insurers will not reimburse family physicians for evaluation and management codes with a psychiatric diagnosis," says Michael L. Szymanski, MD, family physician with Dexter Family Practice in Dexter, Mich.

Carriers often stipulate that they will pay only contracted mental-health providers for mental disorders, says Judy Richardson, RN, MSA, CCS-P, senior consultant at Hill & Associates, a coding and compliance consulting firm based in Wilmington, N.C. "Therefore, these companies usually will not pay an FP for any 300.xx-316 diagnosis (Neurotic disorders, personality disorders, and other nonpsychotic mental disorders)," she says.

Some plans specifically exclude coverage for a diagnosis of ADD (314.00, Hyperkinetic syndrome of childhood; attention deficit disorder; without mention of hyperactivity) or ADHD (314.01, with hyperactivity), Berland says. And some payers do not cover secondary diagnoses, such as V40.0 (Persons with a condition influencing their health status; problems with learning) and V40.3 ( other behavioral problems).

On the other hand, some LRMPs allow FPs to report 314.00. For instance, Trailblazers Health Services, the Medicare carrier for Colorado, New Mexico and Texas, indicates that it will cover 90862 for 314.00 and 314.01. Interestingly, if the FP performs a brief office visit for the sole purpose of monitoring or changing drug prescriptions for ADD or ADHD, Trailblazer says you should report M0064 (Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders) for the medication check. For the initial visit, the policy indicates that it allows medical and osteopathic doctors to report 90801 or an appropriate E/M code. The LMRP, however, fails to list any accepted ICD-9 codes for the visit.

Consider Applicable Alternatives

If you find numerous plans restricting coverage, your FP may have to use another diagnosis, such as encephalopathy, if the code appropriately describes the patient's condition, Berland says. "Many neurologists use 348.3 (Other conditions of brain; encephalopathy, unspecified) for ADD/ADHD evaluations, which FPs also may report."

After contacting your carriers, if you still find reimbursement difficult for these visits, your FP may have to consider referring these evaluations to a behavior-health provider. "The FP will have to weigh the economic impact of doing this," Berland says.

Note: If your FP wants to challenge mental-health carve-outs that he or she believes unfairly discriminate against FPs, see the American Academy of Family Physicians' position paper "Mental Health Care Services by Family Physicians" online at www.aafp.org/x6928.xml.