What CPT codes are used for ADHD evaluation?

Initial psychiatric evaluation uses 90791 (without medical services) or 90792 (with medical services including medication evaluation). Follow-up medication management uses E/M codes 99212-99215 or psychiatric codes 90832-90838 if therapy included. Psychological testing for ADHD uses 96136-96139 (psychologist administered). Document complexity to support code selection.

What documentation is required for ADHD diagnosis?

Document: DSM-5 criteria (≥6 inattention OR ≥6 hyperactivity/impulsivity symptoms), symptom onset before age 12, symptoms present in ≥2 settings, clear evidence of functional impairment, symptoms not better explained by another disorder. Include collateral information (teacher/parent ratings, report cards) and standardized rating scales (Vanderbilt, Conners, ASRS).

What cardiovascular documentation is required before starting stimulants?

Document: personal cardiac history (syncope, palpitations, chest pain, exercise intolerance), family history of sudden cardiac death <50, structural heart disease, or arrhythmia, vital signs including blood pressure and heart rate, and cardiac exam findings. For concerning history, document cardiology clearance or ECG if obtained. Ongoing monitoring required.

How should stimulant medication monitoring be documented?

Document: vital signs (blood pressure, heart rate), weight with percentile for children, height for growth monitoring in children, effectiveness of current dose, side effects (appetite suppression, sleep, mood, tics), and medication compliance. Include rating scale scores if repeated. Document diversion risk assessment for controlled substances.

What documentation supports medical necessity for ADHD medication?

Document: specific functional impairments (academic failure, job performance, relationship difficulties), prior treatment attempts (behavioral interventions, accommodations), severity of symptoms, impact on quality of life, and treatment goals. For non-stimulants, document stimulant contraindications or failures. This supports medication selection and prior authorization.

ADHD Assessment Template - Evaluation and Management

Psychiatry — ADHD Assessment and Management Template

Psychiatry Psychiatry Updated: 11/7/2025

The ADHD Assessment and Management Template is designed for psychiatrists, psychiatric nurse practitioners, and primary care providers evaluating and managing patients with attention-deficit/hyperactivity disorder (ADHD). This comprehensive template documents the diagnostic evaluation process including symptom assessment across multiple settings, functional impairment evaluation, differential diagnosis considerations, treatment planning including medication management and behavioral interventions, and ongoing monitoring of treatment response and side effects. The template follows DSM-5 diagnostic criteria for ADHD and includes sections for symptom history across inattention, hyperactivity, and impulsivity domains, childhood onset documentation, functional impairment in academic, occupational, and social domains, collateral information from family, teachers, or employers, standardized rating scales (Vanderbilt, Conners, ASRS), physical examination including vital signs and growth parameters, cardiovascular risk assessment for stimulant medications, treatment plan with medication selection and dosing, behavioral interventions and accommodations, school or workplace accommodations, and follow-up monitoring. This template supports quality ADHD care, ensures thorough diagnostic documentation, facilitates medication management, and supports academic and occupational accommodations. Ideal for child and adolescent psychiatry practices, adult ADHD clinics, primary care practices managing ADHD, and integrated behavioral health programs.

Chief Complaint

ADHD evaluation / ADHD follow-up / Medication management for ADHD.

History of Present Illness

Symptom presentation: Inattention, hyperactivity, impulsivity.
Onset: Childhood symptoms, current presentation.
Functional impairment: Academic, occupational, social, relationships.
Settings affected: School, work, home, social situations.

ADHD Symptom Assessment

Inattention Symptoms

Difficulty sustaining attention, careless mistakes, not listening, not following through, disorganization, losing things, easily distracted, forgetful.

Hyperactivity Symptoms

Fidgeting, leaving seat, running/climbing inappropriately, unable to play quietly, "on the go", talking excessively.

Impulsivity Symptoms

Blurting answers, difficulty waiting turn, interrupting others.

Collateral Information

Reports from: Parents, teachers, employers, spouse/partner.
Consistency across settings: Yes / No
Duration: Symptoms present for [X] months/years.

Standardized Rating Scales

Vanderbilt / Conners / ASRS scores: [Document scores]
Interpretation: [Clinical significance]

Past Medical History

Relevant: Birth history, developmental milestones, learning disabilities, other psychiatric conditions.

Physical Examination

Vitals: BP, HR, RR, Temp, height, weight, BMI.
Cardiovascular: Heart rate, rhythm, murmurs, blood pressure.
General: Appearance, growth parameters.

Assessment

1) Attention-Deficit/Hyperactivity Disorder, [Predominantly Inattentive / Predominantly Hyperactive-Impulsive / Combined] Presentation

Severity: Mild / Moderate / Severe
Functional impairment: [Specific domains]

2) Differential considered: [Learning disability, anxiety, depression, other]

Plan

1) Medication: [Stimulant / Non-stimulant] — [Drug name, starting dose, titration plan]

Monitoring: Blood pressure, heart rate, growth (pediatrics), side effects.
Expected benefits: [Specific improvements expected]

2) Behavioral interventions: [Parent training, organizational skills, accommodations]
3) Accommodations: [School/workplace accommodations if indicated]
4) Follow-up: Return in [timeframe] for medication monitoring and symptom assessment.

Patient/Parent Education

Diagnosis explained, medication education, expected benefits and side effects, behavioral strategies, accommodations discussed.