Primary Care Coding Alert

Don't let conflicting information on using 90801 and 90862 versus 99214-99215 for ADD/ADHD evaluations rattle your reimbursement. Find out what mental carve-outs mean, if psychiatric codes are right for your family physician (FP), and why knowing your top insurer's local medical review policies (LMRPs) will help get services for mental-health care paid. Be Aware of Carrier-Imposed 90801/90862 Limitations  "Although CPT does not restrict code series to certain providers, many insurance companies allow only behavior health providers to use the 90800 (psychiatry) series," says David I. Berland, MD, chairman of the American Academy of Child and Adolescent Psychiatry (AACAP) codes and reimbursement committee and AACAP AMA CPT advisory committee adviser.

For instance, the LMRP for New Jersey's Medicare carrier, Empire Medical Services, limits coverage of the diagnostic interview (90801, Psychiatric diagnostic interview examination) to physicians certified in New Jersey for psychiatric services. So, if an FP diagnoses a New Jersey Medicare patient with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) and bills 90801 for the visit, the carrier will deny the service. In addition, for subsequent ADD/ADHD visits, in which a physician re-evaluates the patient and/or performs medication rechecks, Empire will pay only psychiatrists for 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy).
 
Numerous FPs receive denials for ADD/ADHD evaluations and re-evaluations for reasons similar to Empire's LMRP, which carves out mental-health services, Berland says. "Insurers' policies vary, making research crucial." Therefore, physicians should find out their major payers' policies and make a list of how each of them wants the services billed. Watch for Plans That Allow E/M Service Although checking insurers' guidelines may seem time-consuming, your practice's bottom line will definitely benefit from knowing your top 20 percent of payers' mental-health coverage rules. For instance, if the New Jersey coder in the above example made a list of Empire's acceptable billing protocols, she would find out that she should substitute an E/M service, such as an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient) or consultation (99241-99245, Office consultation for a new or established patient), for the initial ADD/ADHD interview procedure, provided her FP meets the codes' required elements.

"FPs absolutely should use the E/M codes," Berland says. For the initial and subsequent visits, he recommends billing based on time. "The physician usually spends more than half the time during these visits discussing the patient's diagnosis and treatment plan," he says. When counseling and/or coordination of care dominates (more than 50 percent) the encounter (face-to-face time in the office or other outpatient setting), CPT states that the physician may consider time as the key factor in selecting the level [...]