Pediatric Coding Alert

The parents want to meet with the pediatrician to discuss their childs test results. The child isnt present at the consultation. How should this be billed?

This question comes from Marilyn Phelps, of Pediatric Associates of Bellevue, WA, and it is not an unusual one.

First of all, CPT Codes defines counseling as a discussion with a patient and/or family . . . So family is equal to the patient when it comes to billing based on time for counseling.

Some confusion may be occurring because HCFA has declared that Medicare will only pay for counseling when the patient is present. This is not a concern for pediatrics, however.

Nevertheless, the answer is in the gray zone, says A.D. Jacobson, MD, the medical director of Pediatric Associates of Phoenix, AZ. The problem is what carriers will pay for, however, not what is correct coding. Its debatable whether you can bill if the child isnt present, he says. A lot of it depends on your local carriers.
Jacobson recommends that you document how much time you spend talking to the parents, and also document whether the child is in the room.

I havent seen this be a problem with audits, says Jacobson, referring to the issue of billing when the child isnt actually present, but when the pediatrician is discussing the case with the parents.

The office visit codes99212 to 99215are the most appropriate to use, and base the level on time. For counseling and coordination of care, time is used as an overriding factor to justify the higher code, under CPT. It is important, however, when using time as a factor, to document the amount of time spent on the patients case and the nature of the service provided.

Counseling for ADHD

Jennifer Higgins, billing and insurance manager for Childrens Medical Center, a five pediatrician, one nurse practitioner practice in Martinsville, VA, says her practice isnt comfortable billing for services when the patient isnt present. The situation arises most often with ADHD, she says.

The child may not be in the room the whole time, Higgins reports. They may keep the child in the room for five to 10 minutes, she says. This way, the pediatrician can get an idea of how the child handles him or herself while the parent and doctor are talking. But, then they send the child out to the waiting room, says Higgins. Later, when the session is almost over, the child is brought back in.
The visit usually takes 30 to 40 minutes, but the practice only uses a 99213 code. Thats what the doctors want to use, says Higgins. They chose that level. I know they could charge more.

Note: Although not a coding issue, you may be wondering who is watching the child in the waiting room. Because these visits take so long, they are always scheduled for 4:15, says Higgins. This means that toward the end, the child could be the only person in the waiting room. We have one person on the front desk even after hours, says Higgins. We do end up babysitting.

Other Coding Options

Most counseling in pediatrics is done with the parent anyway, notes Jacobson. Its possible that you could just be talking to the child, he says. But you could also be talking to a parent, or even just a schoolteacher.
There are actually a number of codes that could be used, says Jacobson, who is a member of the American Academy of Pediatrics RBRVS PAC and COPAM.

1. Medical conference (99361 - 99362). This would be the most appropriate code to use, especially if a schoolteacher is involved, says Jacobson. It is to be used only if the patient is not present. The code is under Case Management Services, which is defined in CPT as a process in which a physician is responsible for direct care of a patient, and for coordinating and controlling access to or initiating and/or supervising other health care services needed by the patient. The medical conference is a team conference which is time-dependent. 99361 is for 30 minutes, and 99362 is for 60 minutes. A medical conference is conducted by the pediatrician with an interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient not present).

2. Consultation codes (99241 - 99245). Even though the patient is your own, if youre being requested to evaluate the child for the school, for example, you can use a consultation code, says Jacobson. You can use this code if you are meeting with the parent, the pediatrician adds.

3. Office visits (99213 -99215). Its also possible to use the office-visit codes, says Jacobson. This all comes down to the art of coding, he says. There are a variety of ways that you can code. Perhaps you saw the patient in the exam room first, and then you talked to the parent in your office. If you spent more than 50 percent of your total time counseling the parent, you can use time as factor in determining which code to use. So you might end up with a 99215 even though your actual patient contact only merited a 99213.

4. Preventive medicine counseling (99401 - 99404). These time-dependent codes are another possible option, says Jacobson. These codes are not for treating or counseling patients with symptoms or an established diagnosis, but rather are for promoting health and preventing illness or injury, according to CPT. You might use them if, for example, you are meeting with the teacher because the child is having problems on the playground. You dont know what the problem is, or even if there is a problem. The child may well not be present for this meeting. 99401 is for 15 minutes, 99402 for 30 minutes, 99403 for 45 minutes, and 99404 for 60 minutes.

Tip: Remember that these codes (99401-99404) are to be used only if the parent came in specifically for counseling; you cannot have a sick visit during which you see the child on the same day.