Pediatric Coding Alert

Question: Generally I see a child before referring him/her. But if the patient has a chronic condition, this step is unnecessary. Can I charge 99211 and collect a co-pay for the time involved in making out the referral to the specialist for the chronically ill child?

Texas Subscriber

Answer: While it certainly would be nice to be able to code a 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) for completing referrals, it is not acceptable to use this code for the completion of paperwork. Using a 99211 code still requires the presence of a patient. It is permissible to use this code for a minor visit handled by the nurse or a visit that does not necessarily require the presence of a physician, however the patient must receive a face-to-face service from someone in the office or other outpatient setting.

The CPT 2000 book does have a code for special reports 99080 (special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form). You may consider using this code. However, the insurance company will probably not pay for the referral form to be completed, and if they dont consider this service non-covered you will not be able to bill the patient. In any case, you may not bill the patient for a co-pay without the patient coming into the office.