Pediatric Coding Alert

Question: I haven’t seen a particular patient since 2011, and his account is in collections. His mother called for an appointment for a surgery referral. An emergency department (ED) physician treated the patient on the prior day and told him to follow up with his primary-care physician. Can we give the referral without seeing the patient? We have not seen him for the problem.

Answer: You do not need to provide duplicate care or to evaluate the patient again. The ED physician evaluated the patient and determined he needs a surgeon.

Regardless of the account status, the patient does not need to be seen by his PCP (your physician) for more care. The ED physician determined the course of care and the need for the specialist.

The need for the referral is an administrative requirement of the insurance. If the patient did not have referral-based insurance, he would not call you prior to seeing the surgeon -- he would just follow the ED physician’s instructions and go directly to the surgeon. Based on the ED evaluation and recommendations, you should be OK to give him the referral.

Important: From a risk-management perspective, you may want to see and evaluate the patient (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient …) prior to making the referral. If the patient is in collection, the visit should be on a payment-only basis.

On the issue of the balance owed, you cannot deny care for legal reasons. You can decide to discharge a patient from the practice and follow the appropriate process to do that.

Payment options: You can tell the patient’s parents that you expect payment for the overdue amount at the next visit. Alternative: Tell the patient’s parents that you expect payment for his portion of the visit at the time of service because he has been a bad credit risk.