Pediatric Coding Alert

Question: Which diagnosis should I use for a child who is unable to focus or is inattentive without labeling the child with attention deficit disorder (ADD)?

Maryland Subscriber Answer: During an initial visit for a child whom a teacher or parent suspects of having ADD, pediatricians often don't make a definitive ADD diagnosis. They usually need to collect information from family, teachers and psychological tests, before and after medication prior to confirming ADD.
 
When your pediatrician is unsure of an initial ADD diagnosis, you should code the patient's symptoms. You may use 315.2 (Specific delays in development; other specific learning difficulties) or 312.00 (Disturbance of conduct, not elsewhere classified; undersocialized conduct disorder, aggressive type; unspecified). If a payer has a carve out for mental-health services, it may not cover mental-health-related ICD-9 diagnostic codes.
 
In this case, you may use a V code, such as V40.0 (Mental and behavioral problems; problems with learning), V40.3 (... other behavioral problems) or V40.9 (... unspecified mental or behavioral problem) to describe the child's symptoms. These diagnoses avoid labeling the child with ADD, but the V codes still cause reimbursement problems. Some insurance companies refuse to pay any claim that contains only V codes for the diagnosis.
 
When your pediatrician diagnoses ADD, you should assign 314.00 (Hyperkinetic syndrome of childhood; attention deficit disorder; without mention of hyperactivity).