HOW TO DIAGNOSE AND TREAT ADHD

IN A BUSY PRACTICE

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EDWARD S. CURRY, MD, FAAP (HE/HIM/HIS)

PEDIATRICIAN, KAISER PERMANENTE FONTANA MEDICAL CENTER

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CHAIRPERSON AAP ADHD CLINICAL PRACTICE GUIDELINE SUBCOMMITTEE

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FACULTY DISCLOSURE INFORMATION

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I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.

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I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

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Learning Objectives:

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• Development an efficient office workflow for ADHD evaluation and treatment

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• Increase confidence in diagnosing and treating ADHD and its co-morbidities

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• Access resources necessary to assist in providing outstanding ADHD care to children

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CHANGE IN PRACTICE

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DEVELOP AN EFFICIENT, EFFECTIVE, OFFICE WORKFLOW FOR ADHD ASSESSMENT, TREATMENT, AND FOLLOW UP

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KNOWLEDGE OF THE AVAILABLE ADHD RESOURCE INFORMATION

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Some Statistics Of Note:

Remember these important primary-care practice statistics:

Studies show…

1. That the prevalence of ADHD in the school-age population is approximately 11% (studies range from 8.7-15.5%
2. Approximately 83% of the individuals with ADHD are evaluated, diagnosed, and treated within their primary-care medical home.
3. The majority of children with ADHD also have clinically significant co-morbid Anxiety, Depressive, or Oppositional/Defiant disorders.

OFFICE WORKFLOW

MOST IMPORTANT FACTORS IN HAVING AN EFFICIENT, EFFECTIVE, AND SUCCESSFUL ADHD ASSESSMENT

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• IS HAVING ALL THE BACKGROUND INFORMATION AT START OF THE ASSESSMENT

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• DESIGNATED ADHD CASE MANAGER

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• ADHD ASSESSMENT ARE NOT SCHEDULED UNLESS ALL THE INFORMATION IS RECEIVED

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OFFICE WORKFLOW

FOR ADHD EVALUATION

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OFFICE WORKFLOW

FOR ADHD EVALUATION

OFFICE WORKFLOW

FOR ADHD EVALUATION

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ADHD Parent Orientation Video

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OFFICE ASSESSMENT VISIT

DESIGNATED ADHD CASE MANAGER

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• WHO COLLATES ALL THE PARENT, TEACHER PACKET, AND SCHOOL INFORMATION
• SCHEDULE INITIAL APPOINTMENT 30 TO 60 MIN INITIAL VISIT
• SCHEDULES FOLLOW UP VISIT WITHIN 30 DAYS

-IMPORTANT IF MEDICATION STARTED AT INITIAL VISIT*

• PROVIDES ALL FOLLOW UP INFORMATION, RATING SCALES, AND BEHAVIORAL HEALTH RESOURCES

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*HEDIS GUIDELINES

OFFICE ASSESSMENT VISIT

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OFFICE WORKFLOW

FOR ADHD EVALUATION

OFFICE WORKFLOW

FOR ADHD EVALUATION

OFFICE ASSESSMENT VISIT

Diagnosis

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OFFICE ASSESSMENT VISIT

TREATMENT

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STIMULANT MEDICATION IS THE MOST EFFECTIVE TREATMENT

-Both stimulant and non-stimulant ADHD medications decrease symptoms of

inattention, hyperactivity, and impulsivity.

-Stimulant Response rate 70 to 80 %

IDEAL GOAL IS TO REDUCE ADHD SYMPTOMS AND TOLERATE STIMULANT MEDICATION WITHOUT SIDE EFFECTS

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OFFICE ASSESSMENT VISIT

MEDICATION SELECTION

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- TRY TO BE SUCCESSFUL ON THE FIRST TRIAL OF MEDICATION

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- MY INITIAL CHOICE OF STIMULANT IS METHYLPHENIDATE PREPARATION

-METHYLPHENIDATE TENDS TO PRODUCE LESS IRRITABILITY AND MOODINESS

DURATION OF EFFECT NEEDED

-4, 6, 8, OR 12 HOURS

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-START LOW AND TITRATE UPWARD TOWARD REDUCED ADHD SYMPTOMS

-First Titration upward in 1 week

- Usually start medication on Weekend

- ON STIMULANT MEDICATION

-IF FAMILY DOESN’T SEE ANY CHANGE IN ADHD SYMPTOMS AND NO SIDE EFFECTS THAT’S GOOD SIGN

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OFFICE ASSESSMENT VISIT

MEDICATION SELECTION

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APPETITE AND BODY PROFILE,

-Breakfast

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COEXISTING CONDITIONS

-Oppositional Defiant Disorder

-Anxiety

-Mood Swings

-Autism Spectrum Disorder

-Insomnia

PREVIOUS FAMILY MEMBERS SUCCESS ON STIMULANTS

FAMILY HISTORY DRUG ABUSE

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MEDICATION CASE STUDY

7 year old boy in 2^nd grade who is having ongoing inattention, hyperactivity, and fidgety which was first noted in kindergarten.

He is starting to fall behind academically due to his inattention and lack of completion of school work, and homework. He is starting to have difficulty with his peer due to his impulsive behaviors.

Hx of maternal drug use at birth. Family hx of substance abuse.

Weight 15% BMI 10%. He doesn’t like to eat breakfast. He has some difficulty falling asleep at night. He has some difficulty swallowing pills.

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Parents and Child are open to trying medication.

MEDICATION

www.adhdmedicationguide.com

MEDICATION

www.adhdmedicationguide.com

MEDICATION

ADHD RESOURCES

Resource File – Billing Aids

For more information on billing and coding, I recommend the following resources:

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1: “AAP Coding Hotline” (Service)

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2: “AAP Coding for Standardized Assessment, Screening, and Testing” (Document)

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3: “AAP Coding for Pediatrics 2025” (Manual)

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All of these are AAP resources, available on the

AAP Healthy Children website or

the AAP Bookstore

Resource File – ICD-10 Codes

General: F90 Attention-Deficit Hyperactivity Disorders

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

F90.3 – Attention-Deficit Hyperactivity Disorder, Other Type

F90.9 –Attention-Deficit Hyperactivity Disorder, Unspecified Type

Other Related ICD-10 Codes

F91.3 –Oppositional Defiant Disorder

F84.0 –Autism Spectrum Disorder

F41.x series – Anxiety Disorders

F42.x series – Obsessive-Compulsive Disorders

F32.x and F33.x – Depression Disorders

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Resource File – CPT Codes, New Patient, Using TIME

Office or Other Outpatient Visit, New Patient: CPT 99201 through 99205, Reporting Using TIME

99201 – Range 1-14 minutes day of encounter

99202 – Range 15-29 minutes day of encounter

99203 – Range 30-44 minutes day of encounter

99204 – Range 45-59 minutes day of encounter

99205 – Range 60-74 minutes day of encounter

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Add G2212 – CPT Code for each additional 15 minutes Consult each of your Payors to

OR verify which Code they honor

Add 99417 -- CPT Code for each additional 15 minutes (or both….)

NB: G2212 Not to be used if same-date services 99358 or 99359, 99415 or 99416 are reported

Resource File – CPT Codes, Established Patient,Using TIME

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Office or Other Outpatient Visit, Established Patient: CPT 99211 through 99215

99211 – TIME does not apply for this code

99212 – Range 10-19 minutes day of encounter

99213 – Range 20-29 minutes day of encounter

99214 – Range 30-39 minutes day of encounter

99215 – Range 40-54 minutes day of encounter

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Add G2212 – CPT Code for each additional 15 minutes Consult each of your Payors to

OR verify which Code they honor

Add 99417 -- CPT Code for each additional 15 minutes (or both….)

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Resource File – CPT – Developmental -- Screening Versus Testing

96110 -- Developmental SCREENING: Milestones survey, speech & language delay, with scoring and documentation per standardized instrument.

• Used in conjunction with a preventive care or other E/M code. If multiple standardized screens are performed at the same visit, use code 96110 with multiple units OR on separate line items -- Modifier 59 may be required to indicate services are distinct. You need to check with your PAYORS as to their specific billing requirements.
• Screening occurs when the observer provides his/her observations of the child’s skills, which are then recorded on a standardized and validated screening instrument. It is subjective and relies on the skills of the observer. It does not imply a diagnosis, just simply the means of information collection.

96112 – Developmental TEST ADMINISTRATION (including assessment of fine & gross motor, language, cognitive level, social, memory and/or executive functions by standardized development instruments when performed), by physician or other trained health-care professional, with interpretation and report – FIRST HOUR.

96113 – Each additional 30 minutes (Add-on code, list separately

in addition to code 96112). Also, if codes 96112/96113 are associated

with an E/M code, check with your PAYORS as to their specific billing

requirements for the use of modifiers 25 and 59. When 96112/96113

is reported, the time & effort needed to perform the testing should not

count toward the time for selecting the accompanying E/M code (i.e.

no double-dipping…..)

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Suggested Reference Materials

For more information on this subject, see the following publications:

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Reference A: “AAP Clinical Guidelines for the Diagnosis, Evaluation, & Treatment of ADHD” *

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Reference B: “Caring for Children With ADHD: A Practical Resource Toolkit for Clinicians, AAP 3rd Edition” * *

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Reference C: “ADHD—What Every Parent Needs to Know” Michael I. Reiff, MD FAAP Editor, AAP *

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Reference D: “Evaluation and Management Services Guide” from CMS

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf

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* All of these are AAP documents, available on the

AAP Healthy Children website (Reference A) or

the AAP Bookstore (References B and C)

* A new edition is in the works, not published as yet

Reference Materials

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“Caring for Children With ADHD: A Practical Resource Toolkit for Clinicians, AAP 3rd Edition”

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“AAP Clinical Guidelines for the Diagnosis, Evaluation, & Treatment of ADHD” *

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“Northwest Health Medication Guide: www.adhdmedicationguide.com”

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SPEAKER CONTACT INFORMATION

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EDWARD S. CURRY, MD, FAAP (HE/HIM/HIS)

PEDIATRICIAN, KAISER PERMANENTE FONTANA MEDICAL CENTER

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CURRYAAPCA2@GMAIL.COM

CELL: 909 496-5325

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