Pediatric Coding Alert

Question: We had a patient present for a visit regarding ADHD and the effectiveness of her medication. How should we code this?

Kentucky Subscriber Answer: The correct answer will vary depending on your state and carrier.
O
ne option is to report 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy). Code 90862 can be complicated, though, because it falls under mental-health criteria, and some plans require precertification for reimbursement or have mental-health carve-outs for this code. Also, Medicaid maintains strict frequency guidelines regarding 90862.

Better: Another option is to report a mid- to high-level E/M code such as 99213 or 99214, which you would probably select based on the time that the physician spends counseling the patient and coordinating care, not on the history, exam or medical decision-making portions of the exam. Remember that time must constitute more than 50 percent of the face-to-face encounter to use the time as the driving component of the E/M. Link the E/M code to ADHD (314.01) as the primary diagnosis code.

Report V58.69 (Long-term [current] use of other medications) as the secondary diagnosis to indicate to the carrier that the patient is taking medication for the ADHD. This may be a better option because you don't have to worry about precertification requirements  when you report a standard E/M service. Mental-health carve-outs may still be an issue, however, with the ADHD diagnosis.