Pediatric Coding Alert

When a pediatrician performs a preoperative examination, follow four tips to ethically reap the reimbursement benefits that consultations provide.

Meet Criteria of Consultation

A pediatrician may report a consultation for a preoperative clearance exam if the requirements for billing a consultation are met, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm in Lansdale, Pa. When a specialist requests a preoperative exam, he "needs the pediatrician's consultative expertise to determine if the patient is medically stable for anesthesia or surgery," Falbo says. "The pediatrician incurs the extra medical malpractice risk of 'clearing' a patient for surgery" and thus is entitled to the reimbursement a consultation provides.

Medicare agrees with this interpretation and coding method. "A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation)," states the Medicare Carriers Manual section 15506E. The manual refers to valid sources, such as doctors of medicine (MD), doctors of osteopathy (DO), dentists, podiatrists, optometrists, chiropractors, physician assistants, nurse practitioners, clinical nurse specialists, clinical social workers, nurse midwives, and clinical psychologists, says Brian A. Audler, CPC, which specializes in physician billing education in Chalmette, La.

Most important, this request, either verbal or written, must be noted in the patient's record. "The doctor must ask the pediatrician for clearance of a specific condition," says Mary Gutierrez, CPC, a certified pediatric coding specialist for West Texas Medical Associates in San Angelo. In addition, the pediatrician must send a written report to the requesting physician stating the consultation's findings. The preoperative form fulfills this reporting requirement.

Choose Code Based on Place and Level of Service

"The codes for outpatient and inpatient consultations differ by site-of-service," Audler points out. For outpatient services, use 99241-99245 (Office consultation for a new or established patient). For inpatient consultations, report 99251-99255 (Initial inpatient consultation for a new or established patient).

Select the level of code based on the level of service provided and documented for each of the three principle components: history, examination and medical decision-making. "Upcode the level depending on the intervention required," advises Jeffrey Linzer Sr., MD, FAAP, MICP, American Academy of Pediatrics representative to the ICD-9-CM editorial advisory board.

For instance, suppose a child who has a past history of asthma needs to be cleared for heart surgery. The pediatrician is confirming that the patient is stable for surgery and making sure that the asthma does not require treatment. So, you should report a lower-level code, such as 99242 for an outpatient clearance. However, if the child has had frequent exacerbations, which make additional treatments, such as a steroid boost, prudent prior to surgery, report a higher-level consultation, such as 99244. However, the coding must meet the history, physical and decision-making specified in each coding level.

Ask Payers for Preferred Diagnoses Sequencing

Perhaps one of the most confusing aspects regarding coding for preoperative examinations is the sequencing of diagnosis codes. Part of the problem arises from the need for the coding to reflect the work involved for any underlying conditions. The coding changes depending on the reason the consultation was requested. Regardless of whether an underlying condition exists, you should code the primary reason for the encounter, followed by the reason for surgery.

First, let's look at a preoperative exam that is requested absent any known risk factors. "Some surgeons may elect not to conduct a preoperative clearance, and ask the pediatrician, who is familiar with the patient's history, to make sure the patient is healthy," Linzer says.

For instance, suppose an oral surgeon is removing wisdom teeth for a pediatric patient who has no identifiable risk factors and requests that the pediatrician perform a preoperative consult. You should bill the appropriate consultation code (e.g., 99241) linked to the primary reason for the encounter - the exam - V72.83 (Other specified preoperative examination). Absent any risk factors, the doctor is performing the exam for the purpose of preoperative clearance only. Next report the reason the patient is going to the operating room - dental surgery - (521.0x, Diseases of hard tissues of teeth; dental caries). Both Linzer and Falbo advocate this order of diagnosis sequencing.

Note: The other V codes for preoperative exams, V72.81 (Preoperative cardiovascular examination) and V72.82 (Preoperative respiratory examination), imply a more specific exam that may require a specialist for evaluation. If the patient has an underlying condition that the pediatrician is evaluating, follow the same reasoning. First, report the primary reason for the encounter. Now, be careful here, because this is where interpretive nuances make coding experts differ. The primary reason for the examination is no longer the exam, but the risk factor. The doctor is actually evaluating whether the patient's condition is stable enough to allow surgery. "So, list the medically necessary reason for the consult first, the reason for the surgery, and then the V code," Falbo recommends. For instance, the same patient who is undergoing dental surgery has a heart murmur. So the oral surgeon requests that the pediatrician evaluate the patient to see if the child can tolerate the anesthesia/procedure and needs penicillin prophylaxis. "The pediatrician should bill the appropriate consult code (99241-99245) if in an office setting, with the diagnosis code for heart murmur (785.2, Symptoms involving cardiovascular system; undiagnosed cardiac murmurs) and V72.83," Falbo says. An innocent, functional murmur is not coded at all, Linzer adds. Although many of the experts advise alternative sequencing - for instance, Linzer flips his diagnosis sequencing and reports the V code second and the reason for surgery third - the order does not seem to affect reimbursement. "Payers have varying rules in qualifying medical necessity," Falbo says. To avoid denials, report the reason for the consult, the reason for the surgery and then the V code, she recommends. However, Audler recommends always reporting the V code first, followed by any underlying conditions. Therefore, rather than getting wrapped up in the sequencing, check with your payers. "Identify the payers that want the reason for the surgery or underlying conditions as the primary diagnosis, have them submit you a written policy, and create a manual to reference should anyone question your billing practices," Audler says. "The reimbursement should not vary according to the position of the V code." Prove Medical Necessity for Payment The bigger reimbursement issue is whether the carrier considers the preoperative exam medically necessary. "If there is no medically necessary reason for the consult, the pediatrician runs the risk of the insurance company not paying," Falbo says. "The payer's assumption is that the anesthesiologist can do this preoperative history and physical at the hospital prior to the surgery." Medicare has stated that it will not automatically deny a consult with the V code as primary if the service was medically necessary. If private payers still refuse to pay for V codes, inform them of CMS' rules and that not paying a V code because it's a V code is inappropriate, Linzer says. If the patient's insurance company requires the patient to get a preoperative clearance from his primary-care physician, append modifier -32 (Mandated services) to the CPT consultation code to get paid. Modifier -32 identifies this as a mandated service by the insurance company.