Pediatric Coding Alert

You Be the Coder:

Separate Counseling by Dx in This E/M Encounter

Question: We are billing for an office visit for attention deficit hyperactivity disorder (ADHD), coded properly as a 99215. The provider is also billing 99402, which I am not in agreement with. The visit was strictly to manage the patient’s medications, provide mental health therapy, and discuss anxiety/depression. We typically use 99402 for lactation consultations for our newborns. I know you can bill both with a modifier, but I am stuck on the decision to code this as well.

Pennsylvania Subscriber

Answer: The answer to this question really depends on what your provider discussed with the patient during the counseling session. If the counseling in the evaluation and management (E/M) session is focused on the patient’s ADHD, and your pediatrician reevaluated the patient’s condition, adjusted the patient’s medication, and provided a medication refill, then you should only code 99215 (Office or other outpatient visit for the evaluation and management of an established patient … Typically, 40 minutes are spent face-to-face with the patient and/or family).

However, if the pediatrician spent at least 15 minutes just in counseling concerning the depression as opposed to the ADHD — in other words, the counselling is for a totally different issue — then they could be billed together. So, if there is a separate diagnosis of depression, such as F32.- (Major depressive disorder, single episode) or F33.- (Major depressive disorder, recurrent), you would attach that to the 99402 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes), while F90.- (Attention-deficit hyperactivity disorders) and Z79.899 (Other long term (current) drug therapy) would go on the visit code.

And, because you are billing two E/M codes, you would append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the 99402 counseling code.

Coding caution: If your pediatrician coded by time on the 99215, it’s going to be difficult to separate out the two distinct timed services. Additionally, given that the scope of services offered for the ADHD diagnosis is less once the services for the F90.- diagnosis have been separated out, you may find your payer will baulk at reimbursing. Lowering the level of the E/M service to 99214, or even 99213, and coding by the elements of history, examination, and medical decision making may be your best choice in this scenario.