Time Is of the Essence in ADD Evaluation
Published on Sat Dec 01, 2001
A few weeks after students return to school in the fall and again after the winter holidays, many family physician offices see an increase in requests for evaluation of attention deficit disorder (ADD). Some refer the students to specialists for assessment, but others evaluate patients themselves. Proper coding of these visits is essential because the evaluation and follow-up care can take a lot of time.
"Very rarely are you going to diagnose ADD at the first visit," says Victoria Jackson, CEO of Southern Orange County Pediatric Associates and owner of Omni Management, which provides practice management for 15 medical offices in the Los Angeles area.
Code First Visit as E/M Office Visit or Consultation
Students often come in for assessment after school officials or other agencies suggest that ADD might be causing behavioral or learning problems they have observed in the child. Code this initial assessment as an E/M visit using the 99212-99215 office visit series, says Wendy Walker, CPC, CPCH, certified professional coder at East Petersburg, Pa.-based Central Penn Management Group, a coding and billing facility serving 18 physician offices in Central Pennsylvania.
The first visit typically includes a lot of time spent counseling on ADD, its effects, treatment and impact on schooling. Therefore, coders can use the time component on an E/M visit.
For example, if the physician spends 30 minutes with the patient, with half of that spent counseling, the visit is coded 99214, she says. Sometimes evaluations take longer and can be coded 99215. In that case, the visit must be at least 40 minutes with half the time spent counseling.
If another physician or other appropriate source requests an opinion regarding a child's ADD, you may consider coding the initial encounter as an E/M consultation under the 99241-99245 series (office consultation for a new or established patient).
This is the approach recommended by Jackson, who says that, in California, physicians often perform consultations at the request of school psychologists. She says time spent beyond the typical amount for an E/M consultation may be captured with the prolonged services modifier -21 (prolonged evaluation and management services) or its five-digit equivalent, 09921.
Another option is to use one of the prolonged services codes such as 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour). Code 99354 generally brings higher reimbursement than modifier -21, but the code is less well known and may not be recognized by some carriers. If the physician has long conversations with teachers and other professionals about the child, Jackson suggests using another prolonged services code, such as 99358 (prolonged evaluation [...]
