Pediatric Coding Alert

Submit follow-up consults as subsequent hospital care

The year 2006 will streamline your consult coding by allowing only one type of inpatient consultation service.

Although many experts applaud the ease these changes will bring, some worry about the possible denials the resulting coding may cause. What has prompted these mixed reactions? CPT Codes 2006’s deletion of follow-up inpatient consultations (99261-99263, Follow-up inpatient consultation for an established patient …).

Lump All Inpatient Consults as 99251-99255

This winter, you won’t have to question whether an inpatient consultation is an initial or follow-up consult--a distinction that practitioners have long struggled to comprehend. “Physicians never used the follow-up consultation codes correctly,” says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

You should now use 99261-99263 for visits subsequent to the initial inpatient consult. “During these encounters, the pediatrician must return to review lab work, studies obtained, and the patient’s changed status and cannot co-manage the case,” says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. But CPT 2006 will eliminate this gray area by removing this coding option.

New method: You’ll bill all inpatient consults as 99251-99255 (Initial inpatient consultation for a new or established patient …). Report follow-up inpatient care with subsequent hospital care codes 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …).

How it works: When a pediatrician receives a proper request for a consult in the inpatient setting, you may claim one initial inpatient consult (99251-99255) per hospitalization. But if the pediatrician sees the same patient again during the same inpatient stay, you should report subsequent hospital care codes, not follow-up inpatient consult codes (99261-99263).

Example: A pediatric generalist renders his opinion on an appendicitis patient’s dehydration, while an infectious disease specialist (IDS) addresses the child’s infection. The pediatrician and IDS continue to follow the child during his hospital stay. Because the pediatrician is co-managing the patient’s subsequent dehydration, you should code the subsequent visits with 99231-99233, Callaway says.

Use Right Diagnoses to Capture Dual E/Ms

Paying attention to diagnostic coding will help you avoid denials for two same-day, different-specialist E/M services, some experts say.

In the above subsequent care scenario involving the dehydration/infection/appendicitis patient after the initial consult, the pediatrician and IDS should report subsequent hospital care (99231-99233). Therefore, the insurer will receive two subsequent hospital care claims for the same patient on the same date of service.

Key: Each physician must report the condition(s) he cares for to ensure the dual charge doesn’t trigger a denial. “ICD-9 instructs the physician to list all of the diagnoses he or she addressed during that exam,” Callaway says. For the dehydration/infection/appendicitis patient, the pediatrician would report dehydration (276.5, Volume depletion), and the IDS would report the infection (540.0, Acute appendicitis with generalized peritonitis).

The surgeon would charge for the appendicitis with 44960 (Appendectomy; for ruptured appendix with abscess or generalized peritonitis). The surgery’s 90-day global period would include his related E/M service.

But some experts see two same-day, different- specialist E/M services creating a denial den. “The insurer may bounce out the second same-day E/M code, regardless of the diagnosis coding,” says Peter D. Rappo, MD, FAAP, assistant clinical professor of pediatrics at Harvard University School of Medicine in Brockton, Mass. “This coding change is going to be challenging, payment-wise.”

Gain More Than $10 per Visit

Barring payment obstacles, 99261-99263’s deletion will benefit your bottom line. “Level for level, subsequent care codes pay at a higher rate than follow-up consultation codes,” Callaway says.

Payment comparison: Codes 99231 and 99233 pay $11.75 more than 99261 and 99263, based on the 2005 National Physician Fee Schedule Relative Value File. Code 99232 pays $10.23 more than 99262.