Pediatric Coding Alert

Consult coding is still going strong for some private payers—if you know how to report it.

When Medicare stopped accepting claims for consultations several years ago, many pediatric practices thought that was the end of their consult coding days. However, CPT^® did not do away with the consult codes, and consequently many private payers still reimburse for the service. In fact, earlier this year, United Healthcare solidified its stance on consult coding, noting “UnitedHealthcare will consider a claim for a consultation service for reimbursement if the requesting physician or other qualified source is identified on the claim. If the requesting entity is not identified on the claim, the consultation service will be denied because it does not meet basic AMA requirements for reporting such a code.”

With that in mind, it’s a good time to take inventory of which of your payers still reimburse for consults and which have eliminated pay for these services. Once you have a handle on the payment stats, take a look at these quick tips to ensure you’re reporting consultations correctly.

Know the Ropes of Consults

The definitions for CPT^® consultation codes 99241-99245 state that they are for new or established patients. So if, for example, another practitioner refers a patient to see the pediatrician for ADHD and you have seen the patient within the past three years for otitis media, you can absolutely still report a consult code. The applicable codes are as follows:

• 99241 – Office consultation for a new or established patient, which requires these 3 key components: a problem focused history; a problem focused examination; and straightforward medical decision making ... 
• 99242 – Office consultation for a new or established patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making … 
• 99243 – Office consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity …
• 99244 – Office consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity …
• 99245 – Office consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...

The key to consult reimbursement is that there have to be three key components to a consultation, as follows:

• Request for your doctor’s opinion, which includes the reason for the request (in this case, ADHD)
• Rendering the service in order to develop an opinion (the consult visit)
• A report back to the requesting doctor with the opinion

Using our example above, after your physician creates an opinion on the ADHD and potentially treats the condition, he should send a letter back to the requesting physician stating that you are returning the patient back to him. Outline the details of your plan of care that you stated in your original letter and tell them how it worked out, any modifications you had to make to the plan of care, and the status of the patient.

Invite the requesting physician to not hesitate in sending the patient back to you again if she has any further problems. If your physician feels that the condition he consulted for and treated needs regular monitoring, tell the requesting physician when the patient should check in with your office so you can monitor how she is doing (for example, once a year).

Coding Tip: Never use the word “referring physician”—that indicates that the patient is being sent to the pediatrician to take over the care of the patient.