Pediatric Coding Alert

Question: What codes should we use for attention deficit disorder (ADD)/attention-deficit hyperactivity disorder (ADHD) medication follow-ups? We were denied when using use an evaluation and management (E/M) code but using a preventive medicine code doesn’t seem appropriate. What would you suggest?

California Subscriber

Answer: When the follow-up just involves medication management, 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) …) are not appropriate. That’s because the codes “are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment … and should address such issues as family problems, diet and exercise, substance use, sexual practices, injury prevention [and] dental health …” according to CPT^®. Instead, for an established patient, an E/M code from 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) is more appropriate than a preventive medicine E/M for medication management. In the case of ADD/ADHD medication management, it’s necessary, given that follow-up appointments generally involve some level of examination and/or history.

However, the issue may be the E/M level you submitted or the documentation you use to justify it. If counseling took up more than half of the visit, for example, you may be able to bill the E/M by time, but you must document what your pediatrician discussed with the patient or the patient’s family member(s) in detail. Just saying that your pediatrician counseled the patient is not enough.

And if billing using E/M elements is more appropriate, then remember that though prescription drug management is listed as a clinical example of moderate medical decision making (MDM) (see, for example, the table provided by Centers for Medicare & Medicaid Services (CMS) at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf), you may not be able to bill for a higher-level E/M. Depending on the elements you choose to determine the E/M level, the exam or history your pediatrician performs along with the medication management will probably lower the overall E/M level.