Pediatric Coding Alert

Question: As a primary-care pediatric office, we like to stop in and see our patients and their families when they are hospitalized, but not on our service. We are finding that it is becoming more frequent and are wondering if we could bill for these courtesy visits. Is there an appropriate procedure code we could be using?

Barbara Bennett, Office Manager
Kenmore Pediatric Associates, Buffalo, N.Y.

Answer: If this is truly a social visit, in which you stop by to say hi, the answer is no, you cannot bill for it. This does happen often. But there are many occasions on which a pediatrician might stop by to see a child who is hospitalized by another serviceperhaps in a different hospital from the one you have privileges atand you could bill. First of all, if the attending physician requests that you see the child, that is clearly a consultation (99251-99255 for initial, 99261-99263 for follow-up). Whether initial or follow-up, the consultation must be requested by the attending physician. Take the case of a child who is hospitalized by an orthopedic service. The child has a fractured femur and is in traction. During the hospitalization, the child develops a fever and a sore throat. The orthopedist is not comfortable treating these symptoms and consults the pediatrician.

This is clearly a medical issue, not a social issue, and it is rarely denied. A similar situation might arise if the child in traction becomes somewhat depressed. The orthopedist, again, would probably consult the pediatrician, who could bill a consultation code for visiting the child to review behavioral issues related to the hospitalization.

Following is a real-life scenario which falls in between the purely social visit and the purely medical consultation:

A four-month old, healthy baby, except for some reflux, born full-term, develops RSV and is hospitalized by the primary care pediatrician in the local hospital, which is in a rural area. The baby aspirates formula while hospitalized for RSV. The baby is transferred to the nearest hospital with ECMO capabilities, which happens to be a military hospital. The mother is 14 years old, and the baby is doing so poorly that the pediatrician wants to visit just to let the mother know that Were still there.

This visit could, obviously, become quite prolonged, between discussions with the mother and the attending physician, but the pediatrician travels the 30 miles to the military hospital. And the attending physician, even though he didnt specifically request a consultation, tries to get the assistance of this primary-care pediatrician in dealing with the childs family.

It becomes quite a time-consuming social visit, a far cry from stopping in to say hi to a child in traction while youre doing your regular rounds in your own hospital.

But is it billable? The answer is yes, you can use the confirmatory consultation codes (99271-99275). These codes are to be used when a consultation is initiated by a patient and/or family, and not requested by a physician, according to CPT.

However, the family must have requested that you visit the child. And the purpose of the visit must be confirmatory in nature. In other words, the family might say to you, We have a problem with this babys treatment, and we dont know this physician at this hospital, and we want you to come to see how things are going. Then you must document it in the chart that you were asked by the family member to make this visit.

There is no time allotment for confirmatory consultations in CPT, but you should document the time spent anyway.

Tip: For the psychological well-being of pediatricians who feel trapped by this, dont feel cheated if you dont get paid what you consider your going rate for two hours of work, not to mention the time spent getting to the hospital and back. You probably would have gone anyway, and at least, with a confirmatory consultation, you will be able to bill something.

The other issue involved with this scenario is hospital privileges. You cant go at all unless you have privileges in that hospital. If you choose not to pursue that, you will have to call this a purely social visit and not bill for it.

And it can be quite difficult to get the hospital to grant courtesy privileges in the case of your patient. So if you do want to code a confirmatory consultation, contact the chief of staff and request privileges.

However, there is another way that you can code a confirmatory consultation without getting privileges. It is to document the visit in your own records in the office. (If you cant get privileges, chances are that the hospital where the child is wont let you even look in the chart, much less write in it.) As long as you indicate in the documentation that the talk with the family was done in such-and-such a hospital, it is adequate.

Here is what the pediatrician should do before deciding whether to bill for this visit: First, determine whether the transfer of the patient was a complete transfer of care, or a transfer of care for treatment and management of a particular problem. If other routine care is being continued by the pediatrician, its not a transfer of care.

If you do pay a courtesy visit, in which you stop by and say, hi you would typically put a note in the medical record stating something like, courtesy visit/no charge, and not generate a bill. A confirmatory consultation could be filed if a second opinion is requested by the family for the necessity or appropriateness of a previous recommended medical treatment or procedure.

Tip: Its important to remember that confirmatory consultations are usually reimbursed at the carriers discretion; therefore, its possible that the patients family would have to pay for this.

As an alternative, the pediatrician may be able to bill a subsequent hospital visit (99231-99233). For example, if the pediatrician transferred care to a specialistperhaps to a cardiologist for treatment of a specific heart conditionbut the pediatrician is still following the child for a secondary condition such as diabetes.

In order for the pediatrician to bill for a subsequent hospital visit, the pediatrician must write a note and document the key components in the patient's medical record and must meet or exceed the documentation requirements for billing a 99231-99233.

And the final note on this dilemma is a purely emotional one. These social consultations are of great benefit in building a level of trust and communication between a family and a pediatrician. They are an investment in the doctor-patient relationship. As Richard Tuck, MD, FAAP, puts it, These visits make me feel more fulfilled as a physician.

When he goes to visit a sick child at Childrens Hospital, an hour away, where he does not have privileges, the family is amazed to see him. The family is so grateful, he says. This goes beyond reimbursement.

Answers contributed by: Richard Tuck, MD, FAAP, PrimeCare Pediatrics, Zanesville, Ohio; Kevin Perryman, Administrator, Primary Pediatric Medical Association, Seguin, Texas; Victoria Jackson, Administrator/CEO, Southern Orange County Pediatric Associates, Lake Forest, Calif., Thomas Alan Kent, CMM, president, Kent Medical Management, Dunkirk, Md., Ricardo J. Garcia, CPC, CEO, DRG Associates Consulting Group, Denver, Colo., Susan Callaway-Stradley, CPC, CCS-P, independent consultant, Augusta, S.C.