Pediatric Coding Alert

New Jersey Subscriber

 

Answer: The best answer to the camp/school physicals question is: "Yes, you can charge a consultation code." But you may not want to. The insurer might not pay, and you'll have to bill the parent.

 

Under CPT coding rules, you may use a consultation code (99241-99245) if the request comes from another source, such as a school or camp nurse. Be sure to send a written response back to the requesting source.

 

You may not need to see the child; if you've done a well visit recently, all you need to do is complete the required forms. Some practices charge patients a nominal fee for completing the forms, but again, this is something you may simply opt not to do, out of patient goodwill.

 

Some practices use preventive medicine services codes (99381-99387, new patient; 99391-99397, established patient) but most HMOs allow these codes to be used only at certain intervals (e.g., once a year, once every two years). If you "use up" the preventive medicine services code on a school physical, you may not be able to bill another for that period. Check your contract. 

 

Compare school or camp physicals, which are preventive, to a consultation done at the request of a school nurse who is concerned that the patient may have, for instance, attention deficit hyperactivity disorder. The latter is a true consultation, and you should not have a problem getting paid for it as such. 
 

For surgical clearance, the best option is to have the surgeon consult the pediatrician for the preoperative exam. This allows you to bill the consult codes at a level dependent on the key factors of the visit. For the diagnosis code, report the condition necessitating the surgery.