Pediatric Coding Alert

Question: An insurer is paying us less for consultations than established patient office visits. Is it all right for us to code pre-op consults as office visits?

Kansas Subscriber

Answer: First, you should encourage the insurer to use the AMA/CMS Resource-Based Relative Value Scale (RBRVS), which assigns values to codes to represent work, practice expense, and malpractice insurance cost involved in providing the services and procedures. Special societies, as well as the AMA and Medicare, have approved these values in relation to each other. Having the payer use the fee schedule allows transparency of codes providing you with a payment check and negotiation point.

The RBRVS fee schedule values office consultations (99241-99245, Office consultation for a new or established patient, which requires these three key components ...) significantly more than established patient office visits (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...). For instance, 99241, which requires a problem-focused history, problem-focused examination and straightforward medical decision-making, pays almost $12 more than 99212, which requires two of those three key components. Code 99241 contains 1.34 RVUs (or pays about $51.04), and 99212 has 1.03 RVUs ($39.23), using the 2008 Medicare Physician Fee Schedule.

Second, you should code correctly to properly represent the physician performed and documented services/procedures. If a surgeon has requested a physician's opinion on whether a patient can withstand anesthesia and surgery, and the pediatrician performs the exam and sends his report to the surgeon, you meet CPT's requirements for a consultation (request opinion, render services, and report back). Therefore, a consultation (99241-99245) is the appropriate code choice.

If the service falls short of these criteria, you could instead code the office visit based on the documented history, examination, and medical decision-making.

Best practice: Code the pre-op services correctly. When your contract comes up for renewal, explain the value of providing this service and show the discrepancy in payment between Medicare's and the insurer's rates. Ask them to revalue the consultation codes or to accept the RBRVS system.