Pediatric Coding Alert

Question: A child has attention deficit hyperactivity disorder (ADHD). The mother alone comes in to discuss the medications and the child. No exam can be done. How do we charge the  encounter? Whose name -- the mom or child's -- do we charge any allowed service under? Wisconsin Subscriber Answer: You can report the established patient visit (99212-99215) based on time under the child's name. CPT allows you to use time as the controlling factor when counseling and/or coordination of care dominates the service. For outpatient coding, time includes face-to-face time between the patient and/or family member. Documentation must include the encounter's total face-to-face time, the counseling time, and a brief counseling summary. Time-based coding does not require the encounter to meet any of the visit's otherwise required key components. Established patient office visits that are not comprised mainly of counseling and/or coordination of care would have to meet or exceed two [...]