Pediatric Coding Alert

When a child has a psychosocial problem, depression, or Attention Deficit Hyperactivity Disorder (ADHD), the amount of time the pediatrician spends with the child and parents can be extensive. Most of which is spent on counseling. But if pediatricians want to get paid by managed care, they shouldnt use the psychiatric CPT codes (90804-90899). So how can the pediatrician get reimbursed for these services?

Why Psychiatric Codes are Not the Answer

First of all, it needs to be explained why you cant use the psychiatric codes, which seem to be the most applicable here. Technically, any physician can use any code in CPT, explains Diane Kirkle, CPC, compliance coordinator for Creighton Medical Associates, the physician health organization that is part of Creighton University in Omaha, NE. However, most managed care companies have reserved the psychiatric codes for mental health specialists, and many will only pay those codes for those specialists.

Using the psychiatric codes will guarantee non-payment to most primary care providers, agrees Peter Rappo, MD, FAAP, immediate past chair of the American Academy of Pediatrics (AAP) Committee on Practice and Ambulatory Medicine. Theyre for psychologists and psychiatrists, says Rappo, who practices in Brockton, MA. The reason, he explains, is that managed care companies have separate risk pools for mental and physical coverage. In many cases, the managed care company is already allocating payments for behavioral healthcare in a carve-out, so it confuses the carriers utilization data to have non-behavioral providers (primary care pediatricians) using the psychiatric codes.

Note: A carve-out means that a specific benefit is not covered under the contract between the carrier and the practice, and will be paid separately.

Will Fessenden, billing supervisor for Pediatric Associates of Newark, DE, notes that insurance companies regard pediatricians as primary care providersperiod. If the carrier sees you using a psychiatric code, theyll automatically say youre doing the work of a psychologist or psychiatrist, says Fessenden, who worked in billing for a psychiatric hospital for five years, and who has also worked for an insurance company. You would need a lot of documentation in the chart to use any of these codes, and even if you did, you probably still wouldnt get paid.

Tip: There is one psychiatric code which you can, sometimes, use with success. It is CPT 90862 (pharmacologic management, including prescription, review, and use of medication with no more than minimal medical psychotherapy). This is the code that some insurance companies will let pediatricians use for the regular and periodic Ritalin appointments required for ADHD treatment. However, the RVU for 90862 is 1.38, which is less than the 1.83 for 99214, notes Richard H. Tuck, MD, FAAP, of PrimeCare Pediatrics in Zanesville, OH and a [...]