Pediatric Coding Alert

Often a pediatrician will be asked to do a pre-op physical. And, as everybody knows, health plans only pay for a certain number of physicals per year. Nevertheless, the surgeonand the hospitalneed the clearance from you.

As Nigel Goodman, office manager for Lee-Davis Pediatrics in Mechanicsville, VA, writes: We have been using the routine physical exam codes (99381 - 84, 99291 - 94) for preoperative physicals, but this is being rejected by carriers. What is the correct E/M code for this exam? The diagnosis used is V72.84 . Two coding experts offered these strategies:

1. Use the consultation codes, not the well-visit codes. If you use the well-visit codes, they will probably be rejected because you have already done the maximum amount of well-visits allowed under the health plan for that child. Or, they will be rejected because they dont match up with the diagnosis code. Pre-op physicals are a gray area, admits Carolyn Higgins, accounts manager for Farmville Pediatrics, a solo practice in Farmville, VA. But we use 99241 as a pre-op consult. Higgins is using the lowest level code for an outpatient consultation for pre-op physicals. (See code definitions at the bottom of the page.)

Dari Bonner, CPC CPCH, CCSP, coding reimbursement specialist with Martin Memorial Health Systems of Port Saint Lucie, FL, agrees. Use the consultation codes, she says immediately.

2. Use a specific diagnosis code. The code V72.84 is often rejected by payers because it is not specific enough, says Bonner. Instead, she recommends using either V72.81 (preoperative cardiovascular examination) or V72.82 (preoperative respiratory examination). Ninety percent of the time, it will be V72.81, says Bonner. If you use V72.84, (preoperative examination, unspecified,) and your claims are getting rejected, Bonner says switching to a specific diagnosis code will fix the problem.

Note: This isnt always the case. Higgins does use V72.84, and reports no trouble getting paid.

3. Include the name of the referring physician in the chart. Its very important to put the name of the referring physician in the record, says Higgins. As it states in CPT: The request for a consultation from the attending physician or other appropriate source and the need for consultation must be documented in the patients medical record. You must also document your opinion and any services that you performed and communicated to the requesting physician.

Outpatient Consultation Codes Here are the outpatient consultation codes. Note that there are not separate codes for new and established patients. 99241: Office consultation for a patient which requires a problem-focused history, a problem-focused examination, and straightforward medical decision-making. The presenting problems are self-limited or minor, and typical time spent is 15 minutes. 99242: Office consultation for a patient which requires an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making. The presenting problems are of low severity, and typical time spent is 30 minutes. 99243: Office consultation for a patient which requires a detailed history, a detailed examination, and medical decision-making of low complexity. The presenting problems are of moderate severity, and typical time spent is 40 minutes. 99244: Office consultation for a patient which requires a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity. The presenting problems are of moderate to high severity, and typical time spent is 60 minutes. 99255: Office consultation for a patient which requires a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. Presenting problems are of moderate to high severity, and typical time spent is 80 minutes.