Back to blog

F90.2 Documentation Guide: Expert Tips for Mental Health Providers

Stanley Efrem

Feb 14, 2025

National surveys reveal that approximately 7 million U.S. children aged 3-17 years receive an ADHD diagnosis. This makes ADHD the second most common childhood condition after asthma. Healthcare providers regularly see cases that need the f90.2 diagnosis code, especially when you have about 6 in 10 children with ADHD showing moderate to severe symptoms.

The F90.2 classification represents ADHD combined type, which stands as one of the three main ADHD subtypes in current diagnostic frameworks. Your documentation needs to be accurate and detailed to support proper patient care, insurance reimbursement, and clinical outcomes. This piece offers expert documentation strategies specifically designed for F90.2 cases to help you meet clinical and administrative requirements effectively.

Understanding F90.2 ADHD Combined Type

The F90.2 diagnosis code represents ADHD Combined Type, which stands out as the most common ADHD presentation [1]. This neurodevelopmental disorder shows up through a unique mix of both inattentive and hyperactive-impulsive symptoms.

Clinical definition and criteria

Patients must show a consistent pattern of both inattention and hyperactivity-impulsivity that affects their daily life to get an F90.2 diagnosis. Children under 17 need six or more symptoms from each category [2]. The requirement drops to five symptoms from each category for adults and adolescents aged 17 and older [3].

Key symptoms to document

The diagnostic criteria cover two main symptom groups. Inattentive signs include:

Problems staying focused on tasks
Missing important details
Often forgetting daily activities
Struggles with organization and time management [4]

Hyperactive-impulsive symptoms show up as too much restlessness, trouble staying seated, and often interrupting others [4]. These signs must last at least 6 months and appear in different settings like home, school, or work [5].

Differential diagnosis considerations

Many conditions can look like ADHD, so doctors need to evaluate carefully. Medical issues to think about include thyroid disease, sleep disorders, and hearing problems [6]. Psychiatric conditions like anxiety disorders, mood disorders, and substance use disorders often look similar [7]. 85% of individuals with ADHD have at least one other condition as an adult [7].

Essential Documentation Components

Detailed documentation is the life-blood of managing ADHD combined type effectively. Mental health providers need complete records that support the F90.2 diagnosis code and shape ongoing treatment decisions.

Patient history requirements

Records must show both early and current impairment evidence through detailed diagnostic interviews. Healthcare providers need to collect complete information about presenting symptoms, developmental history, and relevant medical background [8]. A full picture of prior therapy records and medication history helps track how symptoms have evolved over time.

Symptom assessment records

Complete symptom documentation draws from multiple sources. Mental health providers must gather and keep:

Rating scales completed by parents and teachers
Behavioral observations across settings
Academic or work performance evaluations
Third-party interview records
Historical documentation from transcripts and reports [9]

The records should capture symptoms in specific behavioral terms and use age-appropriate rating scales to measure progress [10].

Treatment plan documentation

Treatment plans need updates every 2-4 weeks at first, with less frequent reviews as the patient's condition improves [11]. Providers must track and document:

Medication compliance and side effects
Response to behavioral interventions
Height and weight monitoring for medicated patients
Treatment adjustments based on functioning improvements

Records should show clear communication between everyone involved in the patient's care [11]. Detailed progress notes help track how well treatments work and guide needed adjustments to the care plan.

Documentation Workflow Steps

Healthcare providers who use a well-laid-out documentation workflow can assign F90.2 diagnosis codes accurately and track treatments better. This organized way helps create complete patient records that meet all regulations.

Original assessment process

Getting an F90.2 diagnosis code needs several pieces of information gathered in order. Healthcare providers need to complete these key steps:

Conduct structured interviews with the patient
Gather information from family members and teachers
Document behavioral observations
Review developmental and educational history
Assess medical background
Administer psycho-educational testing when appropriate [12]

A single assessment isn't enough. Providers need to get rating scales from multiple sources to show symptoms in different settings [9]. Standard ADHD tests like TOVA, Conner's Continuous Performance Test, or the Attention Deficit Scale for Adults help confirm the diagnosis [12].

Progress note structure

ADHD combined type progress notes use either SOAP (Subjective, Objective, Assessment, Plan) or BIRP (Behavior, Intervention, Response, Plan) format [13]. All the same, both formats need specific behaviors, interventions, and patient's treatment response documented.

The documentation should include every clinical method we used, especially cognitive-behavioral techniques, mindfulness exercises, or medication management strategies [14]. Progress notes must capture:

Changes in symptom severity
Response to current interventions
Treatment plan modifications
Communication between care providers [13]

Regular follow-ups help track symptoms, overall function, and medication effects in ongoing care documentation [15]. Updates to documentation become needed with behavioral changes or medication adjustments that affect academic or cognitive performance [16].

Common Documentation Errors

Documentation details can prevent common errors that affect patient care and reimbursement for f90.2 diagnosis code cases. Healthcare providers face three big problems with documentation.

Missing diagnostic criteria

Doctors often make quick ADHD diagnoses without documenting all required DSM-5 criteria [17]. They miss recording evidence of early impairment and incomplete symptom documentation. Documentation needs to show symptoms were present before age 12 [18]. The right diagnosis needs proof of difficulties in multiple settings, but providers often miss gathering evidence from both home and school environments [18].

Incomplete symptom documentation

Providers may see symptoms during visits, but detailed documentation needs proof from many sources. Common documentation gaps include:

Missing reports from teachers or workplace supervisors
Lack of detailed behavioral observations in different settings
Incomplete developmental and family history records
Insufficient documentation of symptom duration [18]

The right diagnosis needs evidence of both early and current impairment through detailed diagnostic interviews and source reviews [18]. Many clinicians don't spend enough time gathering complete histories, which can lead to wrong diagnoses [19].

Treatment plan gaps

Poor monitoring and care coordination create treatment documentation errors. Providers sometimes rush from description to treatment without checking if patients meet all diagnostic criteria [19]. Documentation should track how well medications work, responses to behavioral interventions, and regular checks of height and weight for patients on medication [20].

Documentation must show that symptoms disrupt social, academic, or work functions [21]. Missing treatment response documentation leads to poor care adjustments and insurance claim denials [22]. Mental health providers should keep detailed progress notes that show clear communication between all healthcare team members who care for the patient.

Conclusion

Proper F90.2 documentation is crucial to treat ADHD Combined Type effectively and get appropriate reimbursement. Healthcare providers who use an organized documentation process and gather complete evidence from multiple settings help their patients achieve better outcomes.

The success of documentation relies on three main elements: full initial evaluations, detailed progress tracking, and regular treatment plan updates. Providers should take time to collect complete histories and maintain detailed records from different sources instead of rushing through diagnoses.

Documentation acts as both a clinical tool and legal record. Detailed notes help track patient's progress, support insurance claims, and let healthcare team members communicate effectively. Your thorough documentation will give patients the right care based on their specific needs.

Healthcare providers create a strong foundation to manage ADHD Combined Type cases when they maintain complete records and avoid common documentation mistakes. They can handle cases effectively by paying attention to diagnostic criteria, symptom documentation, and treatment monitoring.

FAQs

What is F90.2 ADHD Combined Type?

F90.2 ADHD Combined Type is a neurodevelopmental disorder characterized by persistent patterns of both inattention and hyperactivity-impulsivity that interfere with daily functioning. It's the most common subtype of ADHD, requiring symptoms from both categories for diagnosis.

How many symptoms are required for an F90.2 diagnosis?

For children under 17, six or more symptoms from both inattention and hyperactivity-impulsivity categories must be present. Adults and adolescents 17 and older need only five symptoms from each category for diagnosis.

What are essential components of F90.2 documentation?

Essential components include a detailed patient history, comprehensive symptom assessment records from multiple sources, and a well-documented treatment plan. These should cover presenting symptoms, developmental history, rating scales, behavioral observations, and regular treatment progress updates.

How often should treatment plans be updated for F90.2 cases?

Initially, treatment plans should be updated every 2-4 weeks. As the patient's functioning improves, the frequency of updates can decrease. Regular monitoring of medication compliance, side effects, and response to interventions is crucial.

What are common documentation errors in F90.2 cases?

Common errors include missing diagnostic criteria, incomplete symptom documentation, and treatment plan gaps. Providers often fail to document early impairment evidence, gather information from multiple settings, or maintain detailed progress notes showing treatment responses and care coordination.