Wisconsin Anthem Issues Coding Behavioral and Emotional Disorders Provider’s Guide

December 2019 ~

Anthem Wisconsin has released a guide for providers detailing the proper coding procedure for codes representing behavioral and emotional disorders with onset usually occurring in childhood and adolescence.

ICD-10-CM Coding

Codes within categories F90 through F98 represent behavioral and emotional disorders with onset usually occurring in childhood and adolescence and may be used regardless of the age of the patient.

Attention deficit hyperactivity disorder (ADHD) is characterized by classic symptoms of inattention, hyperactivity, and impulsivity. Three subtypes of ADHD have been identified:

  • Hyperactive/impulsive type – The patient does not show significant inattention.
  • Inattentive type – The patient does not show significant hyperactive-impulsive behavior.
  • Combined type – Patient displays both inattentive and hyperactive-impulsive symptoms.

Other disorders that sometimes accompany ADHD include Tourette’s syndrome, oppositional defiant disorder, conduct disorder, anxiety, depression, and bipolar disorder. ADHD continues into adulthood in about 50% of people with childhood ADHD. Attention deficit hyperactivity disorders are coded based on a behavior type:

  • 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

F90 category includes:

  • Attention deficit disorder with hyperactivity
  • Attention deficit syndrome with hyperactivity

ICD-10-CM lists the following conditions as special exclusions (not included here) to ADHD:

  • Anxiety disorders (F40.-, F41.-)
  • Mood (affective disorders) (F30-F39)
  • Pervasive developmental disorders (F84.-)
  • Schizophrenia (F20.-)

Note from the insurerThis type of exclusion in ICD-10-CM is indicative of conditions that are not included in the F90 category. However, the patient may have both conditions at the same time. For example, if a patient presents with ADHD and anxiety, then both conditions should be coded according to the Excludes2 list. ICD-10-CM often lists conditions in either an Excludes1 or Excludes2 note. It is important that all exclusion notes be followed carefully for coding accuracy. Keep in mind that documentation drives code selection and that the medical record must support all codes submitted on claims.

HEDIS® quality measures for attention deficit hyperactivity disorder (ADHD)

Quality measures are in place to help ensure that patients with specific conditions are receiving the appropriate care and follow-up to successfully manage their conditions. The measure listed below is applicable to those with attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD).

Follow-Up Care for Children Prescribed ADHD Medication (ADD)

This HEDIS measure looks at the percentage of children ages 6 to 12 years who have newly prescribed ADHD medication and have had at least three follow-up care visits within a 10-month period; the first visit should be within 30 days of the first ADHD medication dispensed.

Two rates are reported:

  • Initiation phase — Follow-up visit with the prescriber occurred within 30 days of prescription.
  • Continuation and maintenance phase — Patient remained on ADHD medication and had two more visits within nine months.

When prescribing a new ADHD medication:

  • Be sure to schedule a follow-up right away – The visit must occur within 30 days of ADHD medication initially prescribed or restarted after a 120-day break.
  • Schedule follow-up visits while members are still in the office.
  • Have your office staff call members at least three days before appointments.
  • After the initial follow-up visits, schedule at least two more office visits in the next nine months to monitor the patient’s progress.
  • Be sure that follow-up visits include the diagnosis of ADHD.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Source(s): December 2019 Anthem Provider News – Wisconsin;