Pediatric Coding Alert

Normally, when coding an examination for suspected molestation, the pediatrician should use an E/M services code 99201-99205 for a new patient or 99212-99215 for an established patient. Choose the level based on your documentation of the exam, the history and medical decision-making. For a new patient, all three components must be met to justify coding a certain level. For an established patient, you need two of three.

Note: For more information on how to choose a level of service, see Pediatric Coding Alert, January 2001, page 1.

If counseling consumes more than 50 percent of the time spent with the patient and family, you can use time as a factor in determining your level. For example, if you spend 20 minutes on the exam and 40 minutes on counseling, you can bill CPT 99215 based on time alone.

Most of these encounters would be level five with prolonged services, says Charles J. Schulte III, MD, FAAP, the American Academy of Pediatrics (AAP) representative to the AMA CPT advisory committee and a practicing physician in Washington, D.C. These lengthy sessions would be coded 99215 (on the first line of the claim form) based on time, with +99354 for the first 30 extra minutes of counseling (on the second line). You need to spend a total of at least an hour and 10 minutes with the patient.

Consultation Codes Can Be Appropriate

You can bill a consultation if the request for the exam came from an agency, says Joel Bradley, MD, FAAP, editor of Coding for Pediatrics, a member of the AAP coding and reimbursement committee and a practicing pediatrician in Clarksville, Tenn. The patient need not be referred by another physician to bill a consultation. Human Services fits the requirement of other appropriate source in CPTs definition of consultation.

If you are asked to see the child by Child Protective Services, for example, report the appropriate consultation code with modifier -32 (mandated services) appended, Some private insurers may not pay initially when modifier -32 is appended; check with the payer first to see if you need to file a paper claim.

Dont ignore the high relative value units (RVUs) of consultation codes, says Bradley. The highest office visit code 99215 has an RVU of 3.06. If, however, the pediatrician does the same work (comprehensive history and examination with high-complexity medical decision-making) and the visit is a consultation (99245), the RVU is 5.73. The consultation will usually pay about twice as much, he notes. Even a new patient code 99205 with an RVU of 4.38 would fall short of the highest-level consultation code.

When determining the level based on time, however, remember that consultation codes require more of it. The total [...]