Pediatric Coding Alert

Keeping track of time spent diagnosing, developing treatment plans and providing follow-up care for patients with attention deficit hyperactivity disorder (ADHD) is crucial to receiving optimal ethical reimbursement for ADHD patient care.

Although payers in the past may have been reluctant to reimburse pediatricians for providing mental-health services, increasingly insurance carriers are paying for pediatricians'ADHD evaluation and management.

But be aware that payers will be looking for hard evidence, such as documentation from screening tools and psychological test results, to support ADHD diagnoses. Indeed, insurance companies tend to group certain diagnoses, such as ADHD, depression, anxiety disorders and other diseases that may have psychiatric as well as medical characteristics, into a "mental-health pool," says PeterRappo, MD, FAAP, a practicing pediatrician and assistant clinical professor of pediatrics at Harvard University School of Medicine.

From the insurers'point of view, they've already aggregated the dollars for the ADHD, Rappo says. "So your fundamental question, before you even start, is how to get the diagnosis code accepted." Use V Codes for Unconfirmed ADHD Coming up with a definitive diagnosis for ADHD is not always simple. To confirm a diagnosis, the physician may conduct a multidisciplinary assessment, and these materials may take time to collect.

In addition to supplementary materials such as test results from schools or private psychological testing services, the pediatrician may use diagnostic tools such as those included in the child and adolescent edition of the "Diagnostic and Statistical Manual for Primary Care" (DSM-PC), says David Horowitz, MD, FAAP, a practicing pediatrician with Triangle Pediatric Center in Cary, N.C., and chairman of the mental-health committee of the North Carolina Pediatric Society. (See the note on page 11 for other ADHD diagnostic tools.)

Often, the pediatrician cannot confirm the diagnosis during the initial visit, coding consultants advise.

For unconfirmed ADHD, you can report V codes with the appropriate E/M code. Use V40.0 (Mental and behavioral problems; problems with learning), V40.3 (Mental and behavioral problems; other behavioral problems), or V40.9 (Unspecified mental or behavioral problem). Insurers may not pay when a claim includes only Vcodes for the diagnosis, so don't expect reimbursement. Insurers want a clear diagnosis, but you should also be honest and code for the level of your understanding even if an ADHD diagnosis isn't apparent, Rappo says. Distinguish Between ADHD and ADD When the pediatrician confirms the attention deficit diagnosis, select codes in the 314 series (Hyperkinetic syndrome of childhood), depending on whether the patient has hyperactivity, advises Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. When the patient has attention deficit disorder (ADD) without hyperactivity, report 314.00 (Attention deficit disorder; without mention of hyperactivity). For patients with ADHD, report 314.01 ( with hyperactivity). Time Determines [...]