Primary Care Coding Alert

Solution: Obtain follow-up payment with 99212-99215, not 90862

A simple coding switch can help you ethically avoid denials for Ritalin-monitoring encounters. 
 
Family physician coders often complain of denials for periodic attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) medication re-evaluations with 90862. But as one coder discovered, you can get payment and report your FP's services more appropriately if you instead report 99212-99215.

Payers May Deny 90862 as Psychiatry Code

When your FP provides ADD-ADHD medication rechecks, you may be tempted to use 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy). "Coding seminar experts recommend that we report the encounters with 90862 and 314.0x," says Candy Rogers, billing manager with a primary-care practice in Richmond, Va. "Most payers, however, deny our claims because these codes are mental-health codes and we are not mental-health providers."

Unfortunately, Rogers isn't the only coder having pharmacologic management reimbursement problems. "None of our third-party payers paid for 90862, because CPT lists the code in the psychiatry section," says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Catholic Healthcare Audit Network in Clayton, Mo.

99212-99215 Improves Proper Reimbursement

You can, however, more easily obtain med-check service payment with an E/M code, such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). Physicians who switched to codes 99212-99215 from 90862 report that they receive reimbursement for these follow-up ADD/ADHD visits, Wilkerson says.

Good news: If you use an office visit code instead of the pharmacological management code, you will not only ease your payment problems but also be coding correctly.

Why: ADD-ADHD rechecks typically involve an E/M component.

90862 Involves Medication Management Only

You should use 90862 only at a visit in which a physician provides no psychotherapy and no E/M component. If the physician performs these services, you should include the pharmacological management in the E/M service, Wilkerson says, referring to CPT Assistant summer 1992's instructions.

Bottom line: Because, in most cases, your FP probably performs some psychotherapy, history, exam and/or medical decision-making, you should report these encounters with the appropriate-level office visit code - not the pharmacological management code.

Exam Is Typically Part of Med Follow-Up

A typical ADD-ADHD medication-check encounter usually requires an examination to ensure the patient is eating enough. "A child who is on Ritalin may not exhibit typical weight gain," says Victoria Jackson, executive director and owner of Omni Management in El Torro, Calif.

Because Ritalin is a stimulant, it can suppress an individual's appetite. That's why FPs who manage medication for patients who are in psychotherapy with nonphysician colleagues often periodically check the individual's health prior to writing or renewing a prescription. "To ensure that our patients are eating properly, we monitor weight gain/loss and follow up with blood work when appropriate," Rogers says.

You should report these follow-up visits with the "appropriate lower-level evaluation and management code," Wilkerson says.

Coding example: If the FP performs and documents an expanded problem-focused history and examination, and low-complexity medical decision-making for a patient prior to writing a Ritalin prescription that a psychologist recommended the patient take, you should use 99213.

314.0x Represents the Encounters' Reason

You should continue to use diagnosis codes 314.0x (Hyperkinetic syndrome of childhood; attention deficit disorder) despite payment problems. "Codes 314.00 (... without mention of hyperactivity) and 314.01(... with hyperactivity) appropriately describe ADD/ ADHD,"  Wilkerson says.

Some payers are paying 99212-99215 with 314.0x. Other insurers have mental-health carve outs and may restrict payment for claims containing mental-disorder codes, such as 314.00 and 314.01. In these cases, you may bill the patient for a noncovered service.

You may also want to consider contacting organizations such as the American Academy of Family Physicians or your state insurance commissioner to lobby for primary-care mental-health coverage.