Pediatric Coding Alert

Its a very common scenario: A child is referred to you by the school for behavioral problems, and you are asked to do an evaluation for ADHD. This is a time-consuming assessment. How should you go about getting reimbursed?

Refer Out to Specialist

Referring out is a common solution. Anything that has to do with ADHD, we refer to the pediatric neurologist, says Mark Rafuls, practice manager for Tender Care Pediatrics, a three-pediatrician practice in Miami, FL.

Many pediatric practices gave us the same answer, apparently feeling that the time involved isnt worth the meager compensation they normally get for a third-level office visit.

But it doesnt have to be just a third-level visit. Sandra Bonney, office manager for Pediatric Associates of Alexander City, a four-pediatrician, one-nurse practitioner practice in Alexander City, AL, has come up with an excellent solution to ADHD evaluation problems.

Prolonged Services Codes

One of the doctors has a special interest in ADHD, Bonney explains. It takes one and a half hours to do the ADHD workup. So we started out billing an office visit, using the prolonged services codes (99354-99355) with it. Bonney billed a CPT 99213 for the office visit, and a 99354 for added time the physician spent with the patient that was more than 30 minutes over the normal amount of time spent on an E/M visit of that level.

It is important to note that the doctor documented his time carefully. Code 99354 is for prolonged services, first hour, and can be used for time spent with the patient that exceeds 30 minutes beyond the normal visit time. Taking the example above, CPT states that a 99213-level visit usually takes about 15 minutes. If the physician was with the patient for an hour for the ADHD evaluation, the practice could bill the 99213, plus the 99354. (See related story on billing for prolonged services on page 23.)

Note: The first 15 minutes are allotted to the 99213 code, the next half hour of prolonged service is included in the 99213, according to CPT guidelines. And 99354 can be used for anything beyond 30 minutes up to the full hour. For every half hour beyond the first hour, the practice could code 99355.

But, as so often happens, an insurance company made this coding scenariowhich was technically correctimpossible. Blue Cross of Alabama said we were using two of the same services, says Bonney. They said it was unbundling, and they bundled it. In other words, they would only pay for the 99213.

Code to Higher Level E/M

So Bonneys solution is to upcode the office visit portion to a 99215. Everything the doctor does qualifies it as a comprehensive visit, she says. We now realize the correct way [...]