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ADHD Documentation

  1. #1
    Default ADHD Documentation
    Medical Coding Books
    Our pediatricians will see an established patient for ADHD med checks. The final assessment will be ADHD, stable. If you go strictly by the table of risk, you have 1 established problem, stable, with high risk medication which levels at straightforward medical decision making; our pediatricians believe this should be at least moderate complexity. Does anyone have a pediatric table of risk or advice for ADHD documentation?

  2. #2
    Milwaukee WI
    Default It is what it is
    If that's what is documented, that's what is coded. My doctors hate when I give them this answer, but I can only code what is documented. You are correct that this is an existing problem that is stable, even with Rx management, you will only get straightforward MDM.

    However, with an expanded history and an EPF exam, they can still code 99213, which for "routine" follow-up should be about right for this condition.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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