Pediatric Coding Alert

Four options exist to reap full reimbursement for the time you spend on evaluation and follow-up care of attention deficit disorder (ADD).

"Very rarely are you going to diagnose ADD at the first visit," says Victoria Jackson, CEO of Southern Orange County Pediatric Associates and owner of Omni Management, which provides practice management for 15 medical offices in the Los Angeles area. Code Visits as E/M Office Visit Students often come in for assessment after school officials or other agencies suggest that ADD might be causing behavioral or learning problems they have observed in the child. Code this initial assessment as an E/M visit using the 99212-99215 office visit series, says Wendy Walker, CPC, CPCH, certified professional coder at East Petersburg, Pa.-based Central Penn Management Group, a coding and billing facility serving 18 physician offices. The first visit typically includes a lot of time spent on determining "the differential diagnosis, a diagnostic plan and potential treatment options," says Richard H. Tuck, MD, FAAP, chairman of the American Academy of Pediatrics' task force on reimbursement and pediatrician at PrimeCare of Southeastern Ohio in Zanesville. Therefore, coders can use an E/M visit's time component and, potentially, other codes. For example, if the physician spends 30 minutes with the patient, with half of that spent on counseling, code the visit as CPT 99214 ( physicians typically spend 25 minutes face-to-face with the patient and/or family), Walker says. Sometimes evaluations take longer and can be coded 99215 ( physicians typically spend 40 minutes face-to-face with the patient and/or family). In the latter case, the visit must be at least 40 minutes with half the time spent counseling. Documentation of time spent is critical. The patient usually returns for a second visit, bringing back assessment tools completed by parents and teachers and other information that aid the physician in diagnosing the problem. The pediatrician may also spend time counseling on ADD, its effects, treatment and impact on schooling. Although these follow-up visits often take less time than the first meeting, they typically meet the requirements for 99213, Walker says. Jackson suggests coding either 99213 or 99214. "The medical-complexity level is certainly there" to justify those codes, Jackson says. Because the physician usually spends a lot of time counseling at this appointment, you will probably use the E/M visit's time component to determine the appropriate code. Reporting a Consultation May Be Justified If another physician or other appropriate source, such as a school nurse or psychologist, requests an opinion regarding a child's ADD, consider coding the initial encounter as an E/M office consultation under the 99241-99245 series (Office consultation for a new or established patient).

Jackson recommends this method and explains that in California, physicians often [...]