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, [...]