Pediatric Coding Alert

For referrals in the office setting, you use a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient), Eckis says. In such a case, the specialist assumes care for the patient's problem, which often involves subsequent visits, surgical procedures, ongoing treatment, or follow-up care.

To avoid increasing scrutiny on consultation claims, you must use the consult codes properly. A physician should bill a consult only when the service meets the "three R's" standard, detailed in Section 15506 of the Medicare Carriers Manual (MCM):

Request: A pediatrician or other appropriate source must request a consultation. Any physician may request a consult from any other physician and may perform a consult for his or her own patient as long as the service follows all of the criteria.

"Other appropriate source" is generally understood to mean any individual who can act on the advice or information provided by the consulting physician. The definition here is somewhat open to interpretation but is generally understood to include nurse practitioners, physician assistants and school nurses among others. However, you should always check with the insurer if you have any doubt that an appropriate source has requested a consult.

If the patient contacts the specialist directly, the visit is not considered a consultation unless a second opinion is sought, in which case you should use the confirmatory consultation codes (99271-99275).

Reason: A request for a consultation from an appropriate source and the need for the consult (medical necessity) must be documented in the patient's medical record. A note in the chart should explain why the consultation was requested.

According to the MCM, "In an emergency department or an in- or outpatient setting in which the medical record is shared between the referring physician and the consultant, the request ... may consist of an appropriate entry in the common medical record." In an office setting, there must be specific written documentation of the consultation from the requesting physician, or the consultant's records "must show a specific reference to the request."

Response or Report: According to CPT, the consultant must furnish a written report to the requesting physician. The report should indicate findings, treatments performed and whether the consultant elects to follow up with the patient.

MCM guidelines further specify that the consultation report must be "a separate document communicated to the requesting physician."

Pediatricians must pay particular attention to their documentation - whether they are requesting or delivering a consultation - to provide an accurate record of the patient's treatment.

Always make sure you document the request for a consultation in the patient's record, whether the initial request was verbal or written. Carriers require this documentation to consider the consult code valid. Under the best circumstances, you should keep documentation of this request in the patient's charts - both at the pediatrician's office and the specialist's office.

The wording of the request is important. Physicians should avoid using the word "referral" when they are actually requesting a consultation. Use of this word can imply a transfer of care and be a red flag to auditors. Eckis advises using the term "consult" in the request, a tactic that makes the nature of the visit very clear should there ever be an audit of the information.

Physicians reporting back to the requesting physician following a consultation should be equally careful with "refer," she adds. "In many cases, physicians will write a note stating, 'Thank you for referring Anne Smith to me ...' This is fine for referrals. However, for consults, more appropriate wording would be, 'Thank you for your request to render a consultation ...' "

This can also mean trouble for the specialist in the event of a postpayment audit. In the above example, a pediatrician asked a specialist for a consult. The specialist completed the consult, fulfilling the requirements of the service, including sending the report to the requesting physician. In the course of evaluating the patient, the specialist decided that he should follow the patient's care for the particular problem. However, in his note to the original physician, he thanks the pediatrician for referring the patient to him, when he had, in fact, delivered a consult.

In an audit, a carrier might consider the initial code for a consultation inaccurate, due to the slip in semantics. "It sounds as though the requesting physician sent the patient over to the specialist, expecting the specialist to assume care," she says. If that were the case, a consult code would not be valid.

According to CPT, "A 'consultation' initiated by a patient and/or family, and not requested by a physician," is reported using the confirmatory consultation codes (99271-99275, Confirmatory consultation for a new or established patient). In addition, you can code for these consults when an insurer or other physician seeks a second or third opinion.

CPT designates that confirmatory consults are for "rendering an opinion and/or advice only. Any services subsequent to the opinion are coded at the appropriate level of office visit, established patient, or subsequent hospital care."

These codes can be used with new or established patients, when the patient wants a second opinion, and when an insurer requests a specialist's opinion. Confirmatory consults may be provided in any setting. If an insurer requests the consult to determine medical necessity prior to covering a procedure or service, report the appropriate code with modifier -32 (Mandated services) appended.