Primary Care Coding Alert

Question: A 32-year-old established patient presents to a family physician describing a history of difficulty concentrating, disorganization, missed work deadlines, and trouble completing household tasks. The patient suspects that they’ve had these symptoms their whole life but are only now realizing the extent of the debilitation. The patient asks to be evaluated for attention-deficit/hyperactivity disorder (ADHD). The physician reviews the patient’s medication list and recent thyroid-stimulating hormone and complete blood count results, obtains a history of the symptoms and their effect on work and home functioning, and screens for anxiety and depression. The physician documents “attention and concentration deficit; possible ADHD,” discusses the need for a comprehensive diagnostic assessment, and refers the patient to a behavioral health specialist who evaluates and treats ADHD. The physician documents 32 minutes of total time on the date of the encounter, including record review, the medically appropriate evaluation, counseling, referral coordination, and documentation. No separately reported service is performed. Which codes should I report for the diagnosis and encounter?

New York Subscriber

Answer: For the encounter, the documented total time of 32 minutes on the date of service supports 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded). Although the provider makes a referral, that does not determine the evaluation and management (E/M) level.

Remember, when selecting an office E/M code by time, document the total time — not merely the face-to-face time — and make clear that the work occurred on the date of the encounter. The note should also support the symptom diagnosis by describing the patient’s concentration problems, their duration and functional effect, the conditions considered, and why referral for a comprehensive behavioral health evaluation is appropriate.

For a diagnosis, you can report R41.840 (Attention and concentration deficit), as the provider documented the symptom. Do not assign a F90.- (Attention-deficit hyperactivity disorders) code, as this provider has not confirmed ADHD — and because R41.840 has an Excludes1 note for F90.- ADHD codes, so they should not be reported together.

 In this situation, it’s appropriate to code the documented symptom(s) when the assessment remains uncertain and the patient is being referred for further diagnostic evaluation.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC