Key Coding and Billing Guidelines for ADHD

Attention deficit hyperactivity disorder (ADHD) is a chronic neurobehavioral disorder that is typically diagnosed in children and is characterized by symptoms such as hyperactivity and impulsivity, and/or inattention. In the majority of cases, symptoms continue into adulthood. Coding and sequencing for ADHD depends on the physician’s documentation and adherence to the ICD-10 and CPT coding guidelines. Expert coders in medical billing and coding outsourcing companies can help physicians ensure accurate and detailed coding to capture the clinical evaluation, intervention, treatment, and long-term care management of the ADHD disorder across the patient’s life span.

ADHD is the most common childhood neurobehavioral disorder in the US and the second most commonly diagnosed childhood condition after asthma, according to the American Academy of Pediatrics. A national 2016 parent survey reported that the estimated number of children ever diagnosed with ADHD is 6.1 million and 6 in 10 children with ADHD had at least one other mental, emotional, or behavioral disorder (www.cdc.com). Symptoms may manifest as early as age 3 and continue to present in adulthood as inattention, impulsivity and antisocial behaviors.

Diagnosis

Inattention, hyperactivity and impulsivity are the three key characteristics that define ADHD and the way these features present varies from individual to individual. With effective and timely diagnosis and treatment of children and adolescents, ADHD symptoms can addressed and corrected to achieve optimum outcomes.

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) provides the clinical criteria and guidelines for diagnosing ADHD. To make a diagnosis, children should have six or more symptoms of the disorder present; adolescents 17 and older and adults should have at least five of the symptoms present. There must also be evidence that symptoms began before age 12 years. The DSM-5 list classifies ADHD in three presentations – Predominantly Inattentive, Hyperactive-Impulsive and Combined.

• Predominantly inattentive – difficulty with organization and paying attention.
• Predominantly hyperactive-impulsive – inattention/distraction and inability to focus.
• Combined type – characterized by symptoms of both.

Essential Components of Supporting Documentation for ADHD

• Supporting documentation should include rating scales filled out by parents, teachers, or others; job performance evaluations (if available); third-party interviews; historical information from academic transcripts, teacher comments, tutoring evaluations, and report cards, and other information that the physician deems relevant
• Clinical documentation must clearly differentiate ADHD from hyperkinesia, hyperkinetic syndrome, conduct disorders, and simple disturbances of activity and attention
• The physician must also document the specific type of ADHD: Predominantly inattentive type, Predominantly hyperactive-impulsive type or Combined type

ICD-10 Codes for ADHD

ICD-10 category F90 includes ADHD as well as attention deficit syndrome with hyperactivity.

F90 Attention-deficit hyperactivity disorders
Includes:

• attention deficit disorder with hyperactivity
• attention deficit syndrome with hyperactivity

Excludes2:

• anxiety disorders (F40.-, F41.-)
• mood [affective] disorders (F30-F39)
• pervasive developmental disorders (F84.-)
• schizophrenia (F20.-)

F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type

F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type

F90.2 Attention-deficit hyperactivity disorder, combined type

F90.8 Attention-deficit hyperactivity disorder, other type

F90.9 Attention-deficit hyperactivity disorder, unspecified type

Applicable to:

• Attention-deficit hyperactivity disorder of childhood or adolescence NOS
• Attention-deficit hyperactivity disorder NOS

The DSM-5 guidelines also stress the need for ruling out other causes of ADHD-like symptoms and for identifying comorbid conditions. Common coexisting conditions in children with ADHD include disorders of mood, conduct, learning, motor control, language and communication and anxiety disorders Adults with ADHD may also have personality disorders, bipolar disorder, obsessive-compulsive disorder and substance misuse.

As many diagnosis codes that apply to document the patient’s complexity and report the patient’s symptoms and/or adverse environmental circumstances should be assigned. After a definitive diagnosis is established, the appropriate definitive diagnosis code(s) should be reported as the primary code, including any other symptoms that the patient is exhibiting as secondary diagnoses that are not part of the usual disease course or are considered incidental.

Physician E/M Services – CPT Billing Guidelines for ADHD

Here are key CPT coding guidelines for ADHD from the American Academy of Pediatrics:

• Report office/outpatient evaluation and management (E/M) codes based on time. As the initial assessment usually involves a lot of time for determining the differential diagnosis, a diagnostic plan, and potential treatment options, notes that most pediatricians will report either an office/outpatient evaluation and management (E/M) code based on time as the key factor, or a consultation code for the initial assessment. The appropriate CPT codes should be selected based on the level of service provided for initial evaluation of ADHD of a new / established patient:
  • New office patients (99201-99205)
  • Office or other outpatient visit, established patient (99211-99215)
  • Office or other outpatient consultation, new or established patient (99241-99245)
• Report E/M services using “Time” if counseling or coordination of care takes more than 50% of the physician/patient or family face-to-face encounter. This includes the time the physician spends on such tasks as obtaining a history, performing an examination, and counseling the patient.
• When codes are ranked in sequential typical times (such as for the office-based E/M services or consultation codes) and the actual time is between 2 typical times, the code with the typical time closest to the actual time is used.
• To report prolonged services, the provider must have spent a minimum of 30 minutes beyond the typical time listed in the code level being reported.
• If ADHD follow-up during a routine preventive medicine service does not require an additional evaluation and management service by the physician, then it should be reported under the preventive medicine service and not separately.
• If the follow-up work requires an additional E/M service in addition to the preventive medicine service, it should be reported as a separate service, with modifier 25 on the office-based E/M service.
• Developmental screening and testing services should be reported using CPT codes 96110 and 96112 to 96113.

Appropriate codes should also be used to report physician non-face-face services, psychiatry, psychological testing, non-physician provider services, and NPP care management services, as necessary.

Challenges in Claim Submission for ADHD

An AAP report published in Pediatrics, Vol. 144, No. 4, October 2019, discusses several challenges associated with submitting claims for ADHD and offers recommendations to address these issues. First, providers should review their contracts with payers to identify coverage for services to diagnose or treat ADHD and determine their payment guidelines. They should also identify the correct codes that represent covered diagnoses and services should be identified and these codes should be appropriately linked and reported on claims. In case ADHD is suspected but not yet diagnosed, symptoms such as attention and concentration deficit (R41.840) should be reported. If signs and symptoms of ADHD are absent, screening for ADHD can be reported using code Z13.4, encounter for screening for certain developmental disorders in childhood.

According to the report, the documents posted by health plans on their websites do not always clearly state whether payment for primary care diagnosis and management of ADHD is covered. Moreover, even with documentation that the plan covers primary care services related to ADHD, claims adjudication can erroneously cause denials. Therefore, the report recommends that medical billing service providers should always track and appeal such denials.