Pediatric Coding Alert

Question: I can't seem to collect reimbursement for CPT 99401 when I report it for a consultation with a parent who suspects that her child is being abused. I think the problem is that the child isn't present during the consultation. How can I get paid for this service?

Kentucky Subscriber

Answer: First, you cannot report a consultation code without a third-party referral, so be careful not to consider this counseling service a "consultation."

Code 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) is also not applicable. This code is for a preventive medicine, individual counseling service -- you should not use this code for this type of counseling visit. Physicians primarily report 99401 for general counseling and risk factor reduction interventions provided at a separate encounter, not for interventions provided to patients with symptoms or established illnesses.

For an established patient, your best bet is to charge an established patient E/M code based on time, even if the parent wants to meet with the physician without the presence of the patient. Since you only need to meet two of the three required elements of an E/M code for an established patient, the child does not need to be present because you can exclude the exam component of the E/M.

New patients require documentation of all three components for you to report an E/M service, which means you cannot report this parental counseling service as a new patient E/M code when the patient is not present.

Warning: It will be very difficult to come up with an assessment and a plan for the patient without the patient being present in the office, so your medical decision-making (MDM) will be based on the parents' report, not fact, which will also make determining the MDM level difficult.