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In previous articles, we have provided a summary related to the selection of appropriate Evaluation and Management (E&M) codes (99202-99215) for a sick visit, or as an additional service provided during a well visit. The selection of said E&M code is a key component of pediatric office visits. While previous articles have described how to select the appropriate E&M code based on either Medical Decision Making (MDM) or Time, this article describes an example of how to select the appropriate E&M code for visits related specifically to managing ADHD in children.
ADHD is a chronic disease, prevalent among nearly 10% of all children. For further details on the prevalence of ADHD, please refer to the study conducted by the CDC that contains data from 2016-2019 (http://www.cdc.gov/ncbddd/adhd/data.html). There is a range of complexity that providers manage related to the diagnosis and treatment of ADHD. In general, ADHD is a chronic disease that requires an initial diagnosis, along with follow-up care. Typically, ADHD is initially identified during a well visit, followed by a series of follow-up visits with the pediatric provider. Please continue reading for an example of a common approach on ADHD coding within a pediatric practice.
Parent Expresses Concern of Child at Well Visit: Potential ADHD Diagnosis:
During a well visit for a seven year old child, the provider is asking routine questions aligned with the Bright Futures and/or common approach for key areas to address during a seven-year well visit. The mother of the child expresses some behavioral concerns related to inattention and the inability to follow directions while in school, as well as some accompanying concerns that have been observed for over six months.
During the well visit, the provider takes a full history of the child and completes an initial assessment based on the patient’s behavior. This information is documented in the patient’s chart, with the preliminary belief being that the child is presenting with ADHD. The provider and the parent agree to schedule an assessment visit to confirm this provisional assessment and then, upon confirmation of diagnosis, define the level of ADHD and comprise an initial treatment plan. The provider instructs the mother to complete the ADHD forms (one for her, one for the child, and one for the child’s primary teacher; the practice leverages the Conners Rating Scale). The parent agrees with this approach and schedules the next appointment.
The provider for this visit will then record and select CPT code 99393 – Established Patient Well Visit (5-10 years of age), as well as the appropriate E&M code. In this case, the provider invested 23 minutes into the discussion, background, and information related to ADHD, thus code 99213 would be considered appropriate (Time). Since ADHD is a more complex disease consisting of many factors, code 99214 may also be considered appropriate (MDM) based on specific symptoms and/or complexities presented.
First Initial ADHD Assessment Visit – Confirm ADHD Diagnosis & Severity:
The patient and his mother follow up with the provider a few weeks later with the ADHD assessment forms completed (one by the mother, one by the child, one by the primary teacher). These assessment forms use the Connors scoring tool so that the provider may obtain an objective score. From this, along with parent/patient background and observations, the provider confirms that the ADHD severity should be treated with medication for the best outcome of the child.
The provider reviews background information on ADHD with the parent, as well as common outcomes and/or side effects of the medication that the parent could anticipate with treatment. The provider recommends a follow-up within six weeks. After the visit, the provider sends the ADHD medication to the family’s preferred pharmacy via an electronic prescription.
ADHD is a complex, chronic disease for which the provider is managing a complex medication. This Medical Decision Making meets the guidelines for the selection of CPT code 99214. In this case, the reason for code 99214 is that, during the visit, there was one undiagnosed, new problem with an uncertain prognosis. Additionally, there was data that was reviewed and analyzed from background information provided by the patient’s mother, the scoring tool (including discussion), as well as prescription drug management. More so, the provider should add code 96110 (Developmental Screening; e.g. developmental milestone survey, speech and language delay screen, Autism screen) since a scoring tool was used to assess ADHD.
Initial Follow-up Visit – Assessment of Patient – Adjustments to Treatment Approach:
About six weeks after the appointment at which the child received an ADHD medication prescription, the mother and son attend a follow-up appointment to assess the medication treatment and current progress of the child. During the appointment, the provider identifies that there seems to be some progress in the child’s level of focus and a few behavioral issues, but there were also some reported side effects of the medication.
Based on the assessment, the data for treatment, and the provider’s experience with the medication, the provider makes an adjustment to the medication dose and gives some suggestions to the mother on how to help manage the side effects experienced by the child. The mother and provider discuss the changes and agree on a follow-up appointment in four to six weeks. Since ADHD is a chronic, complex disease and the visit required an adjustment of medication, along with management of a side effect, the provider selects CPT code 99214 (selects E&M code based on Medical Decision Making).
Future Follow-up Visits – Long-Term Management of ADHD:
The child is stable at the next visit, and has made great progress in a number of areas in both school and home, including focus and interaction with others. The provider and the mother agree on a management plan and schedule future visits. The provider uses a time-based approach for the selection of the appropriate CPT code for follow-up ADHD visits. If the visit and data analysis review takes between 20-29 minutes, the provider will select CPT code 99213. If the visit and data analysis review takes between 30-39 minutes, the provider will select CPT code 99214.
Above is one example of an approach to selecting CPT codes related to the management of ADHD at office visits. We hope that the additional information in this article will help providers to enhance their E&M coding selection when treating patients with ADHD.
