ICD-10-CM Coding for Attention-Deficit/Hyperactivity Disorder (ADHD)

By Karen Kostick, RHIT, CCS, CCS-P

Attention-Deficit/Hyperactivity Disorder (ADHD) is a chronic neurobehavioral disorder and often associated with serious areas of impairment and comorbidities over a life span. Physician practice coding professionals are at the forefront to ensure quality ICD-10-CM coded data across a life span for ADHD. In ICD-10-CM, ADHD coding over a life span requires clinical coding expertise across multi-physician specialties including but not limited to psychiatry, pediatrics, internal medicine, and family practice. This article summarizes how complete and accurate ADHD ICD-10-CM coding results in complete and quality coded data for the physician office provider setting.

Diagnosing ADHD

ADHD is a clinical diagnosis based on symptomatology and evidence that the symptoms are interfering with social, academic, or occupational functioning. A comprehensive evaluation is required to diagnose ADHD and consists of a thorough diagnostic interview, information obtained from independent sources such as family members or teachers, diagnostic symptom checklists, standardized behavior rating scales for ADHD, and other types of clinical assessment testing as defined by the clinician.

The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides standardized diagnostic criteria and clinical guidelines for use in the comprehensive evaluation for ADHD. The DSM-5 describes the essential feature of ADHD as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.¹ In DSM-5, ADHD is determined based on the patient’s age, the number and severity of symptoms, the duration of symptoms, the presence of symptoms in two or more settings (i.e., home, school, work), and evidence of symptoms interfering with or reducing the quality of life, social, academic, or occupational functioning. Also, clinicians must be able to determine whether the symptoms are caused by other conditions or are influenced by co-existing conditions.

The DSM-5 edition, released in 2013, incorporated ADHD diagnostic criteria updates, which resulted in more age-appropriate and slightly broadened diagnostic criteria that affects how the disorder is diagnosed in older adolescents and adults.

Noteworthy DSM-5 ADHD diagnostic criteria updates in this area include:

• ADHD was moved to the neurodevelopmental disorders chapter to better reflect how brain development correlates with ADHD. Thus, with the introduction of DSM-5, ADHD is no longer classified as a childhood disorder but as a chronic lifelong disorder.
• Adult symptom examples have been added to the diagnostic criteria to facilitate diagnosing ADHD across the life span rather than just in childhood.
• The age of onset was updated from “symptoms that caused impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”

DSM-5 classifies ADHD in three presentations:

• Predominantly Inattentive Presentation
• Predominantly Hyperactive-Impulsive Presentation
• Predominately Combined Presentation

In addition to the ADHD presentation, DSM-5 further classifies the ADHD severity of the present symptoms as “mild,” “moderate,” or “severe.”

ICD-10-CM ADHD codes are classified in Chapter 5: Mental, Behavioral and Neurodevelopmental disorders. This chapter provides a coding note which states, “Codes within categories F90-F98 may be used regardless of the age of a patient. These disorders generally have onset within the childhood or adolescent years, but may continue throughout life or not be diagnosed until adulthood.”

ICD-10-CM codes for ADHD include:

• 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

The ADHD diagnosis is not established at the time of the initial physician office visit. Therefore, it may take two or more visits before the diagnosis is confirmed or ruled out. ICD-10-CM outpatient coding guidelines specify not to assign a diagnosis code when documented as “rule out,” “working diagnosis,” or other similar terms indicating uncertainty. Instead, the outpatient coding guidelines specify to code the condition(s) to the highest degree of certainty for that encounter/visit, which may require using symptoms, signs, or another reason for the visit.

Also, outpatient coding guidelines state that history codes (categories Z80 – Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. Personal and family history of ADHD has an impact on the clinical assessment of an individual for this disorder; the ICD-10-CM codes to report the history of ADHD in an individual include:

• Z86.59, Personal history of other mental and behavioral disorders
• Z81.8, Family history of other mental and behavioral disorders

Coexisting Conditions with ADHD

According to the National Resource Center on ADHD, more than two-thirds of individuals with ADHD have at least one or more coexisting condition(s). Table 1, above, identifies frequent coexisting conditions in children and adults with ADHD.² Across a life span, some coexisting conditions with ADHD include conduct disorder, depression, and anxiety, which may occur during both childhood and adulthood life stages. Other coexisting conditions with ADHD occur more frequently in childhood such as learning disorders and Tourette Syndrome. Coexisting conditions that occur more often in adulthood stages of ADHD include bipolar disorder and substance abuse disorders.

Due to the high comorbidity associated with ADHD, per outpatient coding guidelines, it is important to code all documented conditions that coexist at the time of the office visit and require or affect patient care, treatment, or management.

Screening and Detecting ADHD

In addition to common co-existing conditions with ADHD, emerging research studies have identified that individuals with ADHD are more likely to experience eating disorders, accidents, physical injuries, and premature death compared to individuals without ADHD. These emerging research topics emphasize the importance of physicians providing consistent screening to individuals with ADHD.

For children diagnosed with ADHD, screening during distinct life stages (young adolescence to teenage to young adult) significantly reduces the risk of developing serious comorbid conditions associated with ADHD. For example, the American Association of Pediatrics (AAP) recommends pediatricians should increase their capacity in providing substance use detection, assessment, and intervention as part of routine wellness exams for older adolescents and teenagers.

This recommendation is particularly important for ADHD individuals who are at a higher risk to misuse alcohol, tobacco, and other illicit substances compared to adolescents without ADHD.³

For undiagnosed adults, physicians are highly encouraged to screen for ADHD in their adult patients during preventive medicine and routine wellness exams. The World Health Organization Adult ADHD Self-Report Scale (ASRS) for DSM-5 is an example of a screening tool for use in the primary care settings.⁴ The scale reflects the DSM-5 adult manifestation of ADHD symptoms, consists of six questions, is easily scored, and has been reported to detect adult ADHD cases in the general population with high sensitivity and specificity.

This type of screening allows primary care physicians who have limited time with each patient to quickly and easily determine whether or not to recommend patients for further ADHD evaluation. The ICD-10-CM Z00.00 – Z00.129 codes for general adult or routine child examinations with and without abnormal findings are used to report ADHD screening and detection during routine health examinations.

Medication Therapy

ADHD includes a multifaceted treatment and the focus is on reducing ADHD symptoms and improving functioning. Effective treatment examples include long-term medication therapy, academic intervention, and cognitive behavioral therapy. Medication (stimulant and non-stimulant) often provides the first line of treatment for many individuals with ADHD, but not all.

The 2017 Merit-based Incentive Payment System (MIPS) includes an important physician ADHD medication quality measure on the percentage of children from six to 12 years of age that were newly dispensed a medication for ADHD who had appropriate follow-up care.

The MIPS quality measure details can be viewed online at https://qpp.cms.gov/mips/quality-measures.

ICD-10-CM code Z79.899, Other long term (current) drug therapy, should be assigned for ADHD individuals who are treated with long-term medication therapy. This status code assignment will assist in differentiating between ADHD individuals who are treated long-term with medication therapy versus ADHD individuals who do not receive long-term medication therapy.

FY2018 ADHD Code Updates

The FY2018 ICD-10-CM code updates that go into effect on October 1, 2017 include updates to ADHD and many coexisting condition codes associated with ADHD. The ICD-10-CM code updates incorporate DSM-5 terminology into the ADHD and associated coexisting condition codes. For example, the inclusion term update for code F90.1, Attention-deficit hyperactivity disorder specifies this ADHD type as ‘hyperactive-impulsive’ which reflects DSM-5 terminology. Also, code F40.1, Social phobias has been updated with the addition of the inclusion term for social anxiety disorder.

Emerging Research Interest and Clinical Initiatives

Over the past several decades, ADHD has only been largely studied in the pediatric and adolescent population. The emergent research interest on adults with ADHD has become of clinical importance as endorsed by the DSM-5 updated ADHD diagnostic criteria specific for adults as well as the recent recommended initiative for physician specialties to integrate the World Health Organization Adult ADHD Self-Report Scale (ASRS) for DSM-5 into wellness exams for undiagnosed adult patients.

The emerging research interest and clinical initiatives have significant potential for an increase in diagnosing and treating ADHD in the physician office setting for the adult population.

More than ever before, when it comes to ADHD coding, physician practice coding professionals need to provide clinical coding expertise to ensure physician practices’ ICD-10-CM coded data completely and accurately captures the clinical assessment, intervention, treatment, and quality long-term care management of the ADHD disorder across the patient’s life span.

Notes

^[1] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association Publishing, 2013. p. 51.

^[2] Children and Adults with Attention-Deficit/Hyperactivity Disorder. “Coexisting Conditions.”

^[3] Harstad, Elizabeth and Sharon Levy. “Attention-Deficit/Hyperactivity Disorder and Substance Abuse.” Pediatrics 134, no. 1 (July 2014).

^{[4 ]} Ustun, B. et al. “The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5.” JAMA Psychiatry 74, no. 5 (May 1, 2017). 

References

American Academy of Pediatrics. “AAP Recommends Substance Abuse Screening as Part of Routine Adolescent Care.” October 31, 2011. 

American Academy of Pediatrics. “ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.” Pediatrics 128, no. 5 (November 2011). 

American Psychiatric Association. DSM-5 Update: Supplement to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association Publishing, September 2016.

Centers for Medicare and Medicaid Services. “2018 ICD-10 CM and GEMs: 2018 Addendum.” 

Centers for Medicare and Medicaid Services. “ICD-10-CM Official Guidelines for Coding and Reporting FY 2017.”

National Comorbidity Survey. “Adult ADHD Self-Report Scales (ASRS).” 

Karen Kostick (karen.kostick@nuance.com) is senior technical business analyst at Nuance Communications, Inc.