Pediatric Coding Alert

Tip: Use time as the key element when reporting counseling encounters

When you discuss problems without the patient present, you can easily capture ethical reimbursement if you employ four easy steps.

Don't let visits in which you see only the parent throw you for a loop. "You should code these encounters the same way you would if the patient were there," says Peter D. Rappo, MD, FAAP, assistant clinical professor of pediatrics at Harvard University School of Medicine in Brockton, Mass.

Here's what experts say you need to know about coding parent-only conferences:

1. Time Is the Dominating Factor 

When parents alone present to discuss their child's care with a pediatrician, you can code the encounter based on time. "CPT offers you a very handy way to report these visits," Rappo says.

Here's how: Choose the E/M level based on the time the pediatrician spends talking to the parents. When a physician spends more than 50 percent of an encounter on counseling, CPT states that you can use time as the controlling factor to qualify for a particular level of E/M services, Rappo says.

You may not realize that parent-only discussions count as counseling. "But when a pediatrician discusses a child's developmental, behavioral or school problem, CPT counts the talking as counseling," Rappo says.

Parents may want to meet privately with you for a variety of issues. Often a parent who suspects her adolescent of abusing a substance, such as drugs or alcohol, wants to meet with the pediatrician about her parental rights, says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association with five pediatric offices in Lake Forest, Calif. "Parents want to know whether they can demand a urine screening." If parents suspect that their  teen-ager is sexually active, they may want advice on approaching the topic with their son or daughter.

Because a pediatrician spends 100 percent of parent-only visits on counseling, you can use time to code these encounters. Therefore, you can use the total face-to-face time that the pediatrician spends with the parents to select the E/M services code , such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).

2. Look at the Level's Time Components
 
To choose the appropriate level, you should refer to the office visit's time designation. Each office-visit level contains a typical time that physicians spend on that service. For instance, when a pediatrician performs 99213, he typically spends 15 minutes face-to-face with the patient and/or family.

Here are typical times that CPT indicates physicians spend with these codes:

99212 - 10 minutes

99213 - 15 minutes

99214 - 25 minutes

99215 - 40 minutes.

Example: Parents request that a pediatrician meet with them regarding their son's recently diagnosed attention deficit hyperactivity disorder (ADHD). The pediatrician spends 40 minutes discussing medications, discipline techniques and school-related issues.

In this scenario, you should report 99215. The pediatrician spends 40 face-to-face minutes counseling the parents.

3. Reject Consultation Coding

Be careful that you report an office visit and not a consultation when a pediatrician performs parent-only services. You may easily confuse these two E/M encounters due to common nomenclature.

Parents often call pediatrician's offices and request a consult. "They may say, 'I want to consult with the physician about my child's behavior problems,' " Rappo says.

Watch out: The way parents and physicians think about consultations is different. A parent thinks of a consultation as talking with the pediatrician across a desk, rather than in an exam room. Physicians, however, must meet specific CPT criteria to bill a consultation.

For a visit to qualify as a consultation, the pediatrician must performs a consultations Three R's (request, render, report). "When a parent requests a pediatrician meeting, the encounter doesn't meet a consultation's report criteria," Rappo says. The pediatrician doesn't send the parent back a report of his findings, as a consultation requires.

In addition, a parent doesn't qualify as a proper requester. You could, however, use a consultation code when a school system or other physician requests the pediatrician's opinion.

Example: A teacher requests a pediatrician's opinion regarding a child's learning disability. The physician examines the child and issues a report to the teacher discussing the child's developmental problems.

You should bill the encounter with an office consultation code (99241-99245, Office consultation for a new or established patient ...). The pediatrician completes a consultations' three criteria:

a proper source, a teacher, requests his opinion

the pediatrician performs a history, examination and decision-making

the physician sends a written report to the requester.

4. Document Time

As with any service, the pediatrician must document the encounter. With a counseling-based visit, documentation should include how much time the pediatrician spends discussing the topic with the parents. Rappo suggests that a possible note could read:

"I spent this many minutes discussing this topic."

Many of the physicians whom Rappo works with at Harvard University School of Medicine are successfully using this technique. "They're understanding the system and including the counseling time and topic in their documentation notes," he says.

Example: Parents of a hospital inpatient who is on kidney dialysis request a meeting with the staff pediatrician to discuss their son's complex medical problems and recent lab results. The pediatrician documents, "I spent 25 minutes discussing treatment options and test results."

Good news: You shouldn't have any trouble with payers reimbursing parent-only visits. Just use the same diagnosis as the topic you're discussing.

Caution: Medicare guidelines, however, require a face-to-face encounter with the patient and do not allow for parent-only counseling visits. Some private payers may adopt Medicare's rules, which are not in line with CPT.