Primary Care Coding Alert

Learn how to overcome potential reimbursement challenges.

Though attention deficit hyperactivity disorder (ADHD) is commonly considered a pediatric condition, primary care practitioners (PCPs) commonly diagnose adults with the condition. Typically, the condition is characterized by symptoms such as hyperactivity, impulsivity, and inattention. However, diagnosing and managing ADHD is not straightforward, and therefore neither is coding ADHD encounters.

Here’s a comprehensive walk-through of symptoms, assessments, and the diagnoses. If your ADHD coding skills could use a little more attention, this one is for you.

Rely Only on Signs and Symptoms Until Official Diagnosis

An established patient presents with difficulty concentrating and paying attention to directions or conversations. The patient describes impulsive behaviors, expresses a lack of self-esteem, excessive worrying, and difficulty regulating emotions. At this encounter, the physician has yet to perform any assessments, but suspects the patient may have ADHD. For this encounter, you’ll stick to coding the symptoms, even if ADHD is listed as the suspected cause of the symptoms.

Report the above listed symptoms with the following ICD-10 codes:

• R41.840 (Attention and concentration deficit)
• R45.81 (Low self-esteem)
• R45.82 (Worries)
• R45.87 (Impulsiveness)
• R45.89 (Other symptoms and signs involving emotional state)

You’re familiar with ICD-10 guideline IV.H, which tells you not to code diagnoses documented as “probable,” “suspected,” Questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms…Code to… symptoms, signs, abnormal test results…” However, the guideline is particularly important for mental health encounters. For example, many ADHD symptoms are also common symptoms of other mental health disorders such as bipolar, generalized anxiety, and autism spectrum disorders, as well as non-psychiatric disorders such as thyroid problems, vitamin B12 deficiency, and even transient stress or grief. Because of the need to assess for ADHD while ruling out other conditions, the evaluation phase typically requires at least two visits, according to the American Academy of Family Physicians (AAFP).

Coding alert: If there are no documented signs and symptoms, but the provider decides to screen for the condition, you may need to report Z13.39 (Encounter for screening examination for other mental health and behavioral disorders).

Accurately Report the E/M Services

Patients under the age of 17 must exhibit six or more ADHD symptoms, and patients over 17 should have at least five of the symptoms. There also needs to be evidence the symptoms began before the age of 12, according to the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5). Be sure to clearly document as much information as possible in case the payers challenge any claims.

Code for time: This type of thorough evaluation means you’ll most likely want to report the evaluation-based encounters using time rather than medical decision making (MDM), so that the provider is sufficiently reimbursed. This will mean selecting from 99202-99215 (Office or other outpatient visit for the evaluation and management of a/an new/established patient…).

Additionally, since ADHD screening tests are often based on self-reported perceptions, and therefore, subjective, the physician may have teachers, parents, and spouses also submit questionnaires to get a more objective look at symptoms. “Time spent reviewing these assessments can be counted toward the time used to report an office/outpatient E/M code if done on the same date as the encounter with the patient,” explains Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Coding alert: If the physician does any work related to an ADHD evaluation and management encounter, but does so on a different date, you will need to report 99358/+99359 (Prolonged evaluation and management service before and/or after direct patient care; first hour/each additional 30 minutes…).

Report 96127 for Most Initial Assessments

Your provider may list any of the following tests in their documentation, all of which can be coded with 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument):

• ADHD Rating Scale IV (ADHD-RS-IV) With Adult Prompts
• Adult ADHD Clinical Diagnostic Scale (ACDS) v1.2
• Adult ADHD Investigator Rating Scale (AISRS)
• Adult ADHD Self-Report Scale (ASRS) v1.1
• Adult ADHD Self-Report Screening Scale for DSM-5 (ASRS DSM-5) Screener
• Adult ASRS Symptom Checklist v1.1
• Barratt Impulsiveness Scale (BIS-11)
• Brown Attention-Deficit Disorder Symptom Assessment Scale (BADDS) for Adults
• Clinical Global Impression (CGI)
• Conners’ Adult ADHD Rating Scales (CAARS)
• Diagnostic Interview for ADHD in Adults (DIVA) 2.0
• Wender Utah Rating Scale (WURS)

Because 96127 is reported “per standardized instrument,” you should report one unit of 96127 for the documented instrument.

Ruling out other conditions: While trying to rule out comorbid or mimicking psychiatric problems, the PCP may refer the patient to a specialist. However, if your practice uses a behavioral health integration (BHI) treatment model, the specialist may already be on staff. You may therefore find yourself faced with using testing codes such as 96116/+96121 (Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment…), 96130/+96131 (Psychological testing evaluation services by physician or other qualified health care professional…), or 96132/+96133 (Neuropsychological testing evaluation services by physician or other qualified health care professional…).

Defer to F90.- for the Diagnosis

When the provider definitively diagnoses the patient with ADHD, you’ll use the details of the notes to report the correct diagnosis code. ADHD has its own set of codes within Chapter 5, and they are as follows:

• F90.0 (Attention-deficit hyperactivity disorder, predominantly inattentive type)
• F90.1 (Attention-deficit hyperactivity disorder, predominantly hyperactive type)
• F90.2 (Attention-deficit hyperactivity disorder, combined type)
• F90.8 (Attention-deficit hyperactivity disorder, other type)
• F90.9 (Attention-deficit hyperactivity disorder, unspecified type)

SDoH alert: Report any applicable Social Determinants of Health along with an ADHD diagnosis. Medication compliance issues, socio-economic situations, alcohol dependence, etc will all play a part in the effectiveness of treatment as well as general patient safety. Also, when these external factors are adequately documented, the physician can more easily refer that patient to a specialist for in-depth services.

Know Potential Coverage Challenges

Some payers carve out coverage of mental and behavioral health services from other services covered by the plan and may even have a separate network of providers for mental and behavioral health services. Providers should review their contracts with payers to determine their payment guidelines for ADHD diagnoses and treatments. Additionally, payers don’t always clearly post whether they’ll reimburse for a primary care diagnosis and management of ADHD. According to the American Academy of Pediatrics (AAP), erroneous denials are common enough that they recommend practices track these instances and appeal.