Pediatric Coding Alert

Question: Our pediatrician makes a lot of phone calls to patients’ parents and other clinicians to talk about symptoms and for case management type of services. He also fills out forms and discusses diagnoses with specialists. These things have become time-consuming for our practice. Can we report some type of code for these services to increase our pay and get the doctors reimbursed for the time spent on these issues?

Answer: You can definitely find codes for such services in CPT 2016, but the answer is whether your insurers will pay for them. First, you should consider the 99441-99443 series for telephone evaluation and management services to parents/ patients if you perform them. These codes are not simply for calling another clinician to chat about a patient’s condition. Rather, they are used for actual E/M services provided to the patient and performed over the phone. They are used when a phone call is initiated by a patient/parent. These codes have very specific criteria for billing, such as the call cannot be about a situation that has a global period, the patient is established, the call leads to a visit within 24 hours or next available time and is not related to a visit within seven days.

You’ll find case management codes listed under 99363-99368. In this series, you will find codes for medical team conferences, whether the patient is present (99366) or not (99367-99368). As for completing forms, you can report 99080 (Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form).

The only hitch is that these codes all have special reimbursement requirements from insurers, if they are payable at all. Whether they are reimbursable will depend upon your specific insurance contract. Often, physicians will roll coordination of care and related services into a patient’s E/M code. In addition, don’t forget that you can select an E/M code based on time spent if counseling or coordination of care comprises at least 50 percent of the visit and is appropriately documented based on time.