Neurology & Pain Management Coding Alert

Key: Don’t forget the E/M component and diagnosis codes.

When you report a follow-up visit for ADD (Attention Deficit Disorder) or ADHD (Attention Deficit Hyperactivity Disorder), do you submit an office visit code or a pharmacological management code? Read on to discover why "office visit" is the correct answer -- and your ticket to avoiding denials and earning your deserved payment.

Remember E/M Is an Essential Component

When the neurologist spends time discussing complaints with the patient and/or family and does a physical examination before prescribing medication for ADHD, report an E/M code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components … Typically, 10 minutes are spent face-to-face with the patient and/or family) or 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components … Typically, 40 minutes are spent face-to-face with the patient and/or family).

Tip: Carefully check the follow-up components. A neurologist will often do a medical examination prior to renewing a prescription. The patient may or may not be on psychotherapy in this case.

Example: The chart might indicate that the patient was on stimulant medication for ADHD and visited your neurologist for a consultation. Since stimulant medications suppress appetite, your neurologist might monitor the patient’s weight gain or loss. In this case, a physical examination and history would be part of the documentation for the encounter. You should report these follow-up visits with the appropriate evaluation and management codes.

In this case, your neurologist performs and documents an expanded problem-focused history and examination, and low-complexity medical decision-making for a patient with ADHD prior to revising the prescription. Hence, you report code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: …Typically, 15 minutes are spent face-to-face with the patient and/or family.).

Check for Pharmacological Management and Psychotherapy

When reporting pharmacological management with psychotherapy, you look at appropriate E/M codes (99201-99255, 99281-99285, 99304-99337, 99341-99350) and the appropriate psychotherapy with evaluation and management service codes, +90833 (Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service [List separately in addition to the code for primary procedure]), +90836 (Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service [List separately in addition to the code for primary procedure]), +90838 (Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service [List separately in addition to the code for primary procedure]). "You report these codes for pharmacologic management with psychotherapy services performed by a physician or other qualified health care professional," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, CO.

You also have a choice to report code +90863 (Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services [List separately in addition to the code for primary procedure]) when your neurologist only does the pharmacological management (such as only a change in the dose of the medication), in addition to a psychotherapy. "The new +90863 CPT^® code was created for use ONLY by those qualified health care professionals licensed to prescribe in their state who are NOT allowed / qualified to bill E/M codes, i.e. payer restrictions," says Hammer. "The code was created primarily for psychologists in Louisiana and New Mexico who do have prescriptive authority in those states but not allowed to report E/M services by some payers."

Bottom line: In most cases, your neurologist will provide psychotherapy in addition to the elements that qualify as E/M services (history, examination and/or medical decision-making). When E/M services are evident, report the encounter with the appropriate-level office visit code instead of a pharmacological management code.

Caveat: Some insurers might deny payment for +90863 because CPT^® lists the code in the psychiatry section. Your best defense as a neurology coder can be a switch to an E/M code. To beat a denial, review your neurologist’s note and consider reporting the appropriate E/M code for a medication-monitoring encounter.

Include the Diagnosis Codes

The ICD-9 coding system offers two codes you can choose from for ADD or ADHD:

Code 314.00 (Hyperkinetic syndrome of childhood; Attention deficit disorder without mention of hyperactivity) includes a diagnosis of predominantly inattentive type of ADHD.

Code 314.01 (Hyperkinetic syndrome of childhood; Attention deficit disorder with hyperactivity) includes a diagnosis of ADHD of predominantly hyperactive/impulsive type, combined hyperactive/inattentive type, simple disturbance of attention with overactivity and overactivity NOS.

Although the descriptors mention "childhood," the same diagnosis codes are used even when the condition is found in adults.

Tip: The best way to choose the appropriate diagnosis code is to check the patient’s chart for the term "hyperactivity."

ICD-10 preparation: When ICD-10 is implemented, the neurologist will need to specifically document if the disorder was predominantly of the inattentive or the hyperactive type. You’ll also have options for a combined disorder. When you are not sure of the type of ADHD, you’ll have an "unspecified" option. Below are the ICD-10 choices:

F90.0 -- Attention-deficit hyperactivity disorder, redominantly inattentive type

F90.1 -- Attention-deficit hyperactivity disorder, predominantly hyperactive type

F90.2 -- Attention-deficit hyperactivity disorder, combined type

F90.8 -- Attention-deficit hyperactivity disorder, other type

F90.9 -- Attention-deficit hyperactivity disorder, unspecified type.

"This is a great example of the increased specificity offered by the ICD-10-CM code set," says Hammer. "Now is the time to work with your neurologist to ensure their documentation includes the necessary details to code to this level of specificity."