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Rejection on DX code 314.00

Gustavo Posted Thu 27th of June, 2013 15:33:30 PM

One of our insurances is rejecting ICD9 code 314.00 when patient comes in for ADD follow up. Is there another ICD9 code that I should be using along with 314.00? What can I do to get this claim paid?

Thanks

SuperCoder Answered Thu 27th of June, 2013 21:12:45 PM

Correctly coding for the diagnosis, the evaluation visit and follow-up visits is crucial to getting optimal payup for attention deficit hyperactivity disorder (ADHD). Many pediatricians are so concerned that ADHD will be difficult to code and bill for that they are referring these patients to child psychiatrists or neurologists. It doesnt need to be that way, but it can be so time-consuming to care for ADHD patients that billing optimally is essential.

Diagnosis Coding

1. Understanding the difference between ADHD vs. ADD. Its important to recognize a key point of confusion for ADHD. The diagnosis codes (314.00 without mention of hyperactivity, 314.01 with hyperactivity, the first is ADD, the second is ADHD, but the coding scenarios are the same) are in the nervous system section of ICD-9, and some insurance companies simply will not pay a primary-care pediatrician for any claim with ADHD as a primary diagnosis.

Peter Rappo, MD, FAAP, a coding expert who practices in Brockton, Mass., and specializes in treating children with special needs, explains that insurance companies lump certain diagnoses into a mental-health pool. This includes ADHD, encopresis, depression, Tourettes syndrome and other diseases that may have psychiatric as well as medical characteristics. Its not just that the insurance company wants a mental-health provider to give services related to a mental-health diagnosisits the money. From the insurers point of view, theyve already aggregated the dollars for the ADHD, says Rappo. So your fundamental question, before you even start, is how to get the diagnosis code accepted.

2. Pre-empt denials with a form letter. Rappo recommends that pediatricians have a form letter ready for these cases. The letter should go with the claim and should state that ADHD is a medical diagnosis, and it should include your best clinical reasoning. This tends to decrease the denials, says Rappo. Dont even wait for denials; send a copy of the letter with the claim, unless you know the insurance company understands this issue.

3. Correctly using the V codes. Its not that simple to come up with a definite diagnosis for ADHDits not like testing for strep throat. There are V codes which can be used: V40.0 (mental and behavioral problems; problems with learning) and V40.3 (mental and behavioral problems; other behavioral problems). These, at least, avoid labeling the child with ADHD. However, some insurance companies refuse to pay any claim that has only V codes for the diagnosis.

Our sources recommend 314.00 or 314.01 for the visit if the patient does have ADHD, and V40.0 or V40.3 for that visit if the diagnosis is not yet known. Diagnosis coding is based on signs and symptoms until the diagnosis is established, explains Richard H. Tuck, MD, FAAP, founding chair of the American Academy of Pediatrics (AAP) committee on coding and reimbursement (formerly the RBRVS PAC). It might be that at the first visit, you wouldnt have a diagnosis, says Tuck, who practices with Primecare Pediatrics in Zanesville, Ohio. You might not have that diagnosis until the next visit.

The Evaluation Visit

Rappo feels that a lot of the concern surrounding the time involved with the initial evaluation is unfounded. Some people think the only way to (diagnose ADHD) is an eight-hour evaluation, he says. Theres no code for an eight-hour evaluation, and so they dont get paid. But you can actually do the evaluation in 45 minutes to an hour, says Rappo. One doctor does an eight-hour evaluation, gets an ADHD diagnosis, and puts the kid on Ritalin, says Rappo. The guy down the road does a 45-minute evaluation, gets an ADHD diagnosis, and puts the kid on Ritalin. Both dealt with behavioral, medical, school and other issues.

It might be possible to break up the evaluation into three separate days, billing for each day, says Rappo. You could do the office visit one day, testing the next and counseling the next, he says. But this is not something a busy pediatrician is likely to have time for.

I would probably use a higher level code for the initial evaluation, says Lee S. Thompson, MD, FAAP, a member of the AAP committee on coding and reimbursement who practices with Aurora Pediatric Associates, a six-pediatrician practice in Denver, Colo. There is an element of time involved. Remember, time can be used to determine a level only if counseling takes up 50 percent or more of the time spent with child and/or parents.

Tuck recommends a 99215 be used for the initial evaluation, since this almost always takes 45 minutes or more. If necessary, you should use prolonged services codes as well, says Tuck. Youre reviewing a lot of information.

A lot of this depends on what the managed-care company will pay for, says Bruce Meyer, MD, FAAP, chief ambulatory officer at Columbus Childrens Hospital in Columbus, Ohio, and a member of the AAPs ADHD subcommittee. I will code this a high level, he says. If the insurance company wont pay, I just write it off.

Thompson also has families fill out a questionnaire during the evaluation, and codes for that using 96110 (developmental testing; limited [e.g. Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report). Note that you must write an evaluation into the medical record to bill for this code.

Follow-up Visits

Coding for the follow-upswhich are really Ritalin visits during which the patient gets a new prescription depends on what you are doing. Methylphenidate, the generic name for Ritalin, is on Schedule II of the Controlled Substances Act, the most restricted category of legal drugs. Most states require monthly prescriptionsyou cannot give refills. Pediatricians handle this in different ways.

Some pediatricians give predated prescriptions once a child is stable on medication, which the parent must hold on to and take to the pharmacy each month. The parent holds onto the prescriptions, not the medication. If these are lost, they cant be replaced. Parents guard them carefully, however, and are happy to be spared the inconvenience of returning to the office just to get a new prescription.

Some pediatricians require children to come in for new prescriptions, but do not charge, since they feel that the parent would resent paying a co-pay just to get a new prescription. Rappo says that this is shortsighted. If you use 99211 because the nurse pulls the chart etc., you have to be willing to charge the co-pay, he says. Physicians scream endlessly about how unfair the insurance companies are to them, but then they wont even charge a co-pay when they should.

Billing for Phone Calls

If a parent calls about a child on Ritalin and says things arent going well, pediatricians often spend time on the telephone with this parent. I would call them and spend five, 10, or 15 minutes on the phone, says Meyer, who doesnt charge for these calls. But you can charge.

This is one of the clearest examples of how pediatricians could charge for telephone calls, says Tuck. These codes (99371, 99372, 99373) are not always paid by insurance companies. But pediatricians spend a lot of time on the phone for ADHD patients, talking to the teacher, the school psychologist, says Tuck. I do use these codes, and I tell the parents that its likely their insurance company wont pay, and that they will have to pay.

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