Pediatric Coding Alert

You can still bill an E/M code based on time to most insurers.

It happens in pediatric practices almost every day—parents make an appointment to speak with the physician about a child’s issues while the child is at school—then your practice is in a bind about how to report the visit. Since the patient (the child) wasn’t present, can you bill any code at all?

Most pediatric practices see their options as reporting a consult code (99241-99245), but some are concerned that their insurers are slowly joining Medicare in eliminating these codes from the payment schedules. Other practices want to report an E/M code (99201-99215) or preventive medicine counseling codes (99401-99404). In most cases, however, only one of these choices is correct.

Report an E/M Code Based on Time

If the patient’s parents or guardians present to the practice to discuss the patient’s condition with the pediatrician, you should report the visit based on time that the parents spend with the doctor using an E/M code from the 99201-99215 series.

Because the pediatrician is performing counseling based on an active condition that the patient has, you are justified in reporting the appropriate E/M code based on face-to-face time counseling or coordinating care.

When you’re billing based on time, CPT^® defines “face-to-face time” as “only that time spent face-to-face with the patient and/or family. This includes the time spent performing such tasks as obtaining a history, examination, and counseling the patient.” Because CPT^® uses the language “with the patient and/or family,” it’s clear that the patient need not be present to report these codes under CPT^® rules.

Example: A nine-year-old established patient is diagnosed with ADHD by a psychiatrist. The parents are concerned and present to the pediatrician to discuss appropriate management and treatment options while the patient is at school. The doctor takes the patient’s history and then counsels the parents on the condition for 25 minutes. In total, 30 minutes are spent with the parents on that date.

In this case, the visit should be coded based on time as a key factor, as there will only be a history and straightforward medical decision-making, says Donelle Holle, RN, pediatric coding consultant and president of Peds Coding, Inc. “Billing based on time as a key factor means the physician has to document his total time and then the amount of time in counseling and what was discussed,” she adds. When billing based on time, at least 50 percent of the visit must involve counseling and/or coordination of care.

Therefore, the documentation might say, “Mr. and Mrs. Smith presented to discuss Isabel’s recent diagnosis of ADHD. They were concerned with the potential side effects of medication and how they can manage her condition without meds. We spent 30 minutes together, 25 of which were spent discussing how she can best manage her ADHD, medication options, the side effects of medication, how to ensure she gets enough rest and exercise, and what to look for in terms of her behavior.”

The rules change if Medicare’s involved: Although CPT^® rules support reporting the E/M codes without the patient present, CMS sings a different tune. “CMS states that the patient has to be present,” Holle says. In some cases, such as a patient with a severe disability or one in end-stage renal disease, even pediatric patients will be covered under Medicare, and for these patients you cannot bill the E/M code if the patient isn’t in the room.

Here’s Why Consults May Not Work

If your practice has always reported these services using the consult codes (99241-99245), chances are you may be coding incorrectly, even if your payer still recognizes the consult codes. That’s because a consultation requires three key elements, the majority of which are often not being met in situations like this.

According to CPT^®, a consultation is billable when you provide it “at the request of another physician or appropriate source.” In addition, the pediatrician has to then see the patient, and then report his findings back to the requesting physician. In our ADHD example above, the pediatrician’s visit with the parents does not meet any of these criteria.

Because the psychiatrist has already diagnosed the patient with ADHD, chances are that he isn’t asking your pediatrician’s opinion on managing the patient. He is instead transferring the patient’s ongoing care to your office. Without the referring physician’s written or verbal request for consult, you cannot report a consultation code. In addition, your doctor isn’t examining the patient or reporting his findings back to the psychiatrist – he is simply discussing the diagnosis with the parents. A parent or caregiver cannot request a consultation—consequently, those codes should not be used in the situation described above.

Avoid the Preventive Medicine Counseling Series

Although the preventive medicine counseling series (99401-99404) may look appealing in these situations, CPT^® clearly states that these codes “are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.” In the case of the child with ADHD, the doctor is clearly discussing a specific illness.

You’ll instead report preventive medicine counseling in situations such as patients who want diet and exercise or safe sex counseling, and other preventive issues that the physician would address using a counseling session.