First, Don't waste your time fighting this issue. As far as your billing manager goes they are right on the mark. This is one of the battles that you should just walk away from. Look for the battles that you at least have some chance of winning. Because the plan defines these codes as Mental Health Codes they have State and/or Federal law on their side. Specifically if it is an individual policy they have the Texas Department of Insurance Rules and Regulations on their side for benefit coverages provided. If the plan is an employer plan then it falls under ERISA as a Benefit Plan issue. Second, recognize this fact and develop office policies to handle the issue in the future. Many insurance carriers will not pay for ADD/ADHD work ups performed by pediatricians. However they will pay when performed by a Neurologist or psychologist or psychiatrist. Inform the families up front that many insurance carriers consider this to fall under mental health benefits and that if you perform the evaluation the family may have to pay the full charge. Also, let them know that if they chose to they can have the evaluation performed by a neurologist or a psychiatrist, they may not be liable for the services as insurance may cover it under their benefits. At that point it is the patients choice on what to do. The best thing to do is to know that codes in the 290-319 series are Mental Health Codes and that they are not reimbursed to PCP's. Know that when patients call to schedule evaluations for School Problems, Behavior problems, Antisocial behaviors, etc. that they need to be informed that as a PCP you can see them for those problems, however, most insurance companies do not reimburse such services in the PCP office and that they may be better off seeking care from a Neuro or Psych. Tell them they need to call their plan and verify coverage and that after doing so they can call back if they want to be seen by you. When they come be sure to have them sign a waiver stating everything you told them and that they may be responsible based on their insurance plans determination of benefits. If denied as a non-covered service by a PCP they will be responsible for the charges. Finally, after the initial diagnosis is made, you are no longer seeing the patient for 314.00 or 314.01 but for V58.69 Management of Long-term High Risk Medications. Typically you are seeing the patient for medication adjustments Adderall, Strattera, etc. Bill a level 99213 or 99214, some cases 99215. ************************************************************************ ************** Billing 99212, 99213, 99214 with V58.69 We are paid 100% of the time from BC/BS of Texas without any problems. ************************************************************************ ************** Some alternatives are as follows: we have billed initial evaluations but the initial evaluation are not billed as 314.00 or 314.01 since the diagnosis typically is not complete and the concerns were not specific to ADD/ADHD. We code based on signs and symptoms, Forgetfulness (780.93 memory loss), Lack of coordination (781.3). We also have used 'Secondary Diagnosis' codes as primary with some carriers without problems, i.e. V40.0 Problems with learning, V61.29 Parent-Child problems, other, V62.81 Interpersonal Problems, NEC, V40.3 Behavioral Problems, V62.3 Educational Circumstances - Dissatisfaction with school environment. BCBS has accepted some of the secondary dx codes as primary but not all. Most other insurance carriers accept the secondary as primary. Cigna is the only carrier that I have had that repeatedly denied all secondary Dx codes as a secondary and they needed a primary dx code. Remember, you are a provider of service. You are not an insurance carrier, you do not write the insurance benefits or coverage rules. If patients and families get upset at you, redirect the anger toward the insurance carrier. "I understand your upset, however I must follow the rules that are set by YOUR insurance carrier. I did not write the insurance policy, your insurance carrier did. Therefore, you can take the issue up with the insurance carrier or with the Texas Department of Insurance. As the insured individual you have more rights under the law then I do as the provider of service to appeal the decision of the carrier." Hope this helps, Take care, Kevin Perryman Kerrville, Texas (830) 896 - 2758 -> -----Original Message----- -> From: [mailto:] -> On Behalf Of Ajey Godbole -> Sent: Tuesday, August 03, 2004 10:24 PM -> To: -> Subject: Fw: BCBS not paying for ADHD -> -> -> ----- Original Message ----- -> From: Ajey Godbole -> To: -> Sent: Tuesday, August 03, 2004 10:23 PM -> Subject: BCBS not paying for ADHD -> -> -> I was informed by my billing manager that BCBS of Texas is -> not paying the practice for a patient with ADD (without H) I -> have seen 6 times in the office already. Apparently they and -> a lot of other insurance companies in Texas are not paying -> for 'mental health' diagnoses if billed by a primary care -> provider. They will only pay for these diagnoses if seen by -> a 'mental health professional'. The subliminal msg. is: bill -> for 'something else' and it will get paid. -> -> I wonder if any of you has run into this. I am drafting a -> letter to send with an appeal of the denials and I plan to -> fight it for months if necessary but my manager tells me it -> is futile! -> -> =ajey -> -> ------------------------------------------------------------- -> ---------- -> questions: "" or -> "http://www.pcc.com/lists/"; To unsubscribe: -> mail -> "" with "unsubscribe" ->