Pediatric Coding Alert

The AMA and CMS don't see eye-to-eye on what a consultation requires. Try your hand at three pediatric scenarios to check whether your consultation coding correctly qualifies for these higher-paying services (99241-99245, Office consultation for a new or established patient ...), which pay 25 percent to 42 percent more than corresponding new patient office visits (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...).

Scenario 1: A school registered nurse (RN) sends you a child who has failed a hearing test. Does this meet a consultation's second R (request)?

Answer 1: Yes by CPT, says Joel Bradley Jr., MD, FAAP, medical director for the Cumberland Pediatric Foundation in Tennessee. CPT allows a consultation request from another physician or other appropriate source.

Example: An appropriate source could be a teacher or a school nurse, says Richard H. Tuck, MD, FAAP, pediatrician with PrimaryCare of Southeastern Ohio in Zanesville, Ohio. The teacher could request the pediatrician's opinion on the child's behavior, such as possible attention deficit disorder or attention deficit hyperactivity disorder, and how to handle it in the classroom. Or, as in scenario 1, a school nurse could ask a pediatrician's opinion on a child who failed a hearing screen, he says.

Watch out: CMS limits the requesting source to a physician or nonphysician practitioner (NPP). So a school nurse or teacher would not qualify as a generating source.

Think CMS restriction doesn't matter to you When billing Medicaid, first follow the CPT definition, says Donelle Holle, RN, past coding and reimbursement director for the department of pediatrics at the University of Michigan Health Systems in Ann Arbor. For instance, for a request from a school nurse, consider a consult code. If the carrier rejects 99241-99245 due to its consult definition, refile the charge with a corrected code, either a new (99201-99215) or established (99212-99215) patient office visit code," Holle says.

Scenario 2: You complete a preoperative form that a surgeon requested for a child who has a heart murmur and is scheduled for wisdom-tooth extraction. Does completing this form satisfy a consultation's report requirement?

Answer 2: Yes. The form constitutes a written report, so you could use a consult code for the pre-op encounter if the service meets the other consultation requirements. A separate complete letter is not necessary. The report can be the preoperative form from the surgeon or a scoliosis form from a school nurse, Tuck says.

Do this: Make it crystal-clear to a future auditor that the form serves as the report. Here's how: On the top of a pre-op form, state letter of communication for consultation, says Holle in Nuts & Bolts of Pediatric Coding at The Coding Institute's 2007 pediatric coding conference.

Scenario 3: A health-department physician refers a child to you for increased hemoglobin levels. Should you code a consult or an office visit?

Answer 3: An office visit (99201-99215). The problem with coding this case as a consult is the term refers, Bradley says. CPT's definition of a consult involves a request for opinion or advice regarding evaluation and/or management of a specific problem. Referring implies the initial physician is turning the patient's care over to you.

Tip: Check whether an encounter fulfills the circle of care. In the above case, If the health-department physician wants you to take the patient and manage his care, the encounter isn't a consult, Bradley says. You have a consult if the doctor wants you to tell him what he should do about the increased levels and you issue a report to him recommending the treatment course.

The same is true of requests from emergency departments (EDs) for follow-up treatment. Although you may complete and return the ED-issued follow-up form, unless the ED physician is expecting to manage or co-manage the patient's care, a consult isn't appropriate, says Rhonda Buckholtz, CPC, director of local chapters for the American Academy of Professional Coders.