Optimize Reimbursement for ADHD
Published on Wed Mar 01, 2000
Correctly coding for the diagnosis, the evaluation visit and follow-up visits is crucial to getting optimal payup for attention deficit hyperactivity disorder (ADHD). Many pediatricians are so concerned that ADHD will be difficult to code and bill for that they are referring these patients to child psychiatrists or neurologists. It doesnt need to be that way, but it can be so time-consuming to care for ADHD patients that billing optimally is essential.
Diagnosis Coding
1. Understanding the difference between ADHD vs. ADD. Its important to recognize a key point of confusion for ADHD. The diagnosis codes (314.00 without mention of hyperactivity, 314.01 with hyperactivity, the first is ADD, the second is ADHD, but the coding scenarios are the same) are in the nervous system section of ICD-9, and some insurance companies simply will not pay a primary-care pediatrician for any claim with ADHD as a primary diagnosis.
Peter Rappo, MD, FAAP, a coding expert who practices in Brockton, Mass., and specializes in treating children with special needs, explains that insurance companies lump certain diagnoses into a mental-health pool. This includes ADHD, encopresis, depression, Tourettes syndrome and other diseases that may have psychiatric as well as medical characteristics. Its not just that the insurance company wants a mental-health provider to give services related to a mental-health diagnosisits the money. From the insurers point of view, theyve already aggregated the dollars for the ADHD, says Rappo. So your fundamental question, before you even start, is how to get the diagnosis code accepted.
2. Pre-empt denials with a form letter. Rappo recommends that pediatricians have a form letter ready for these cases. The letter should go with the claim and should state that ADHD is a medical diagnosis, and it should include your best clinical reasoning. This tends to decrease the denials, says Rappo. Dont even wait for denials; send a copy of the letter with the claim, unless you know the insurance company understands this issue.
3. Correctly using the V codes. Its not that simple to come up with a definite diagnosis for ADHDits not like testing for strep throat. There are V codes which can be used: V40.0 (mental and behavioral problems; problems with learning) and V40.3 (mental and behavioral problems; other behavioral problems). These, at least, avoid labeling the child with ADHD. However, some insurance companies refuse to pay any claim that has only V codes for the diagnosis.
Our sources recommend 314.00 or 314.01 for the visit if the patient does have ADHD, and V40.0 or V40.3 for that visit if the diagnosis is not yet known. Diagnosis coding is based on signs and symptoms until the diagnosis is established, explains Richard H. Tuck, MD, FAAP, founding [...]
