Pediatric Coding Alert

Question: Under what circumstances may we use the office consultation codes?

Massachusetts Subscriber

Answer: To bill a consultation (99241-99245), another physician or other appropriate source must request the service, according to CPT. The request may be written or verbal, but the physician must document it in the patients medical record and provide a written report to the requesting source.

The physician may treat the condition for which he or she was consulted and still bill a consultation code for that initial visit. The consultation codes are not separated into new or established patients, and you can bill a consultation on your own patient.

Another physician is always an appropriate source from which to receive a request for a consult. Other sources include:

Emergency department: You could definitely bill an outpatient consultation code if the emergency department physician requests that the pediatrician see a patient. The pediatrician receives a phone call at the office, or at home in the middle of the night when on call, for instance, and reports to the hospital right away to see a child who is suffering an asthma attack; admission is being considered. If the pediatrician admits the child, bill a hospital admission code; if, however, the pediatrician sends the child home, bill a consultation code. Document the request in the childs chart, and send the emergency department physician a written report or a copy of the dictated note.

Family practitioner: This involves a patient who is not the pediatricians. A family practitioner is treating a child and feels that the expertise of a pediatrician is needed. Therefore, he or she asks that you see the child. This is another example of a physician request, and the health plan should pay without a problem.

Presurgical clearance: Your own patient, perhaps with asthma, may require presurgical clearance before dental surgery, for example. Bill a consultation if the surgeon requests that you provide advice about the childs ability to tolerate the anesthesia. Use the diagnosis code for the condition that requires the surgery as the primary diagnosis code, and the diagnosis code for the asthma or other complicating condition as the secondary diagnosis code.

School nurse: This is a common example, and although it should not be problematic, it often is. The school nurse may think a child has a problem, such as hearing difficulties or scoliosis (both the subject of school screenings). If the nurse refers the patient to a pediatrician, a consultation is justified. Be sure to note the request in the chart and to report all findings to the nurse.

Follow CPT guidelines so you can argue with any payer for your right to bill a consultation. But bear in mind that some private payers require that the consultation be requested by someone they refer to as a billable provider most often, a physician or nurse practitioner. They may not feel that a school nurse is qualified to request a consultation.