Pediatric Coding Alert

New York Subscriber

 

Answer: If the emergency department (ED) physician wants your opinion, yes, you can bill for a consultation. If the patient is being transferred to you for care, you can't.

 

If, for example, the ED doctor felt he couldn't handle a case of asthma and called you to take over the care, you would bill either a hospital admission (99221-99223) or an outpatient code (99214 or 99215, most likely) if the patient were discharged to home from the ED. If, however, the ED doctor wanted your opinion about a petechial rash and called you, you could bill a consultation code. At issue is your intent -- and intent is derived from the requesting provider's note. Experts recommend that physicians spend time discussing the format of ED requests.

 

Remember, you can bill a consultation only provided that you follow the rules for consultations:

 

(1) The pediatrician must be requested by another physician to provide an opinion or advice regarding evaluation and/or management of a specific problem

 

(2) Need for a consultation must be documented, and

(3) The pediatrician must write a report for the requesting physician.

 

There is still some confusion over whether a pediatrician can bill a consultation and go on to treat the patient. The Medicare consultation guidelines were clarified in 1999 to make it clear that a doctor can bill a consultation and subsequently treat the patient, providing the three above criteria are met. According to transmittal 1644, a revision to section 15506 of the Medicare Carriers Manual, Medicare carriers must pay for a consultation "regardless of treatment initiation unless a transfer of care occurs."