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MP 3.01.01 Attention Deficit Disorder (ADD)

Medical Policy
Section
Mental Health
Original Policy Date
12/01/95
Last Review Status/Date
Reviewed by consensus/2:2003
Issue
2:2003
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Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Attention deficit disorder (ADD) is classified as a state characterized by a persistent pattern of inattention or hyperactivity-impulsivity.

Inattention may be manifest in academic, occupational, or social situations. Individuals with this disorder may fail to give close attention to details or may make careless mistakes in schoolwork or other tasks. Work may be messy and performed carelessly and without considered thought.

Attention deficit disorder can be subdivided into inattention with hyperactivity, and inattention without hyperactivity, or impulsivity.

Hyperactivity may be manifested by fidgetiness or squirming in one’s seat, by excessive running or climbing in situations where it is inappropriate, by having difficulty playing or engaging quietly in leisure activities, by appearing to be often “on the go,” or by talking excessively.

Impulsivity manifests itself as impatience, difficulty in delaying responses, blurting out answers before questions have been completed, difficulty awaiting one’s turn, and frequently interrupting or intruding on others to the point of causing difficulties in social, academic, or occupational settings.


Policy

Attention deficit disorder is classified as a Mental Health condition. Stimulant medication is medically necessary in the treatment for attention deficit disorder. Behavioral management is helpful in some cases, but not required.


Policy Guidelines

Evaluation prior to the diagnosis of attention deficit disorder is considered medical.


Benefit Application

BlueCard/National Account Issues

Attention deficit disorder is classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as a Mental Disorder, therefore classifying any treatment under the Mental Health or Psych benefits.

Prescriptions for drug therapy are processed under the Prescription Drug benefit. Visits for counseling, behavioral management, psychotherapy, etc., should be processed under the Mental Health benefit. Pediatricians may treat children with the disorder by office visit and drug prescription; this should adjudicate as an office visit and the drugs under Prescription Drug. Coding of CPA 90862 by pediatricians for this service is appropriate. But this CPA code is classified under psychiatric therapeutic procedures and will therefore adjudicate under the Mental Health benefit.


Rationale

A search of the literature was completed through the MEDLINE database for the period of January 1992 through April 1995. The search strategy focused on references containing the following Medical Subject Headings:

– Attention Deficit Disorder with Hyperactivity 

Research was limited to English-language journals on humans.

 

Codes

Number

Description

CPT  90841 Individual psychotherapy by a physician, with continuing medical evaluation and drug management when indicated, including insight-oriented, behavior modifying, or supportive psychotherapy; time unspecified
  90842  75-80 minutes
  90843 20-30 minutes
90844 45-50 minutes
90862 Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy
90887 Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons, or advising them how to assist patient
ICD-9 Procedure  94.33  Behavior therapy
ICD-9 Diagnosis 314.00 ADD without mention of hyperactivity
314.01 ADD with hyperactivity
314.8 ADD residual type
HCPCS  J8499 Prescription drugs, oral, non-chemotherapeutic, not otherwise specified
Type of Service  Mental Health
Place of Service 

Outpatient

Physician's office 


Index

Attention Deficit Disorder (ADD)

Hyperkinetic syndrome


Policy History

Date Action Reason
12/01/95 Add to Mental Health section New policy
07/12/02 Replace policy Policy reviewed by consensus; new review date only
07/17/03 Replace policy Policy no longer scheduled for review


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