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ADHD consultation without patient

Shaila Posted Mon 19th of December, 2011 18:42:46 PM

An ADHD patient's parents came for a consultation that the parents wanted without the child present. The doctor coded the visit as a 99214 based on time, but my understanding is that you cannot use an E/M code without a patient present. I showed him the CPT book where it says "The first 3 of these components (history, examination and medical decision making) are considered the key components in slecting a level of E/M services." Without the physical exam there can be no E/M service provided, correct?

What then can we use? 96150-96155 and 99401-99429 are all face-to-face codes. 99354-99357 (face-to-face prolonged services) involves patient contact, and 99358-99359 refers to indirect contact *after* there was a face-to-face encounter. Medication management, 99605-99607, refers to services done by a pharmacist.

The closest thing I could find was 90846 (family psychotherapy without the patient present)...would that be correct coming from a pediatrician for an ADHD consultation?

SuperCoder Answered Tue 20th of December, 2011 15:43:29 PM

Hi Shaila.

Let me say first that I'm not a pediatric coder/biller so I can't speak specifically to ADHD but here are my thoughts.

If you look at the full descriptor of the E/M codes (99201-99205 & 99212-9915), it states in there: "counseling and/or coordination of care with other providers, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family needs" and "physicians typically spend x minutes face-to-face with the patient and/or family." Depending on the payer, I would think some may allow you to bill for the ADHD consult with the parents using an E/M code (99214) based on this.

However, I know some payers won't pay for without some element of patient face-to-face even if you're billing based on time (where the key components don't matter). I think you'll need to check with your payer specifically.

Again, depending upon the payer's policy you may also be correct that you could bill 90846. However, many insurance companies have special regs for billing mental health services, some require prior authorization, etc.

One option you have is to bill the patient/family directly as self-pay for this service. This may actually be your best bet for these types of visits to ensure you get paid, unfortunately. Or, your physician could always have the patient (the child) come in and spend just part of the time in the room during the "consultation," perhaps when discussing treatment options toward the end. You can then use the time portion of the E/M code to determine which code to use.

I hope this helps some.


Leesa A. Israel, BA, CPC, CUC, CMBS
Executive Editor, The Coding Institute
Manager, TCI Consulting & Revenue Cycle Solutions
Home office: (866) 458-2973

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