Pediatric Coding Alert

Question: A surgeon sends you an established 1-year-old patient with chronic otitis media (OM) and hearing loss who is scheduled for placement of ventilation tubes tomorrow. The surgeon asks you to "clear" the patient for anesthesia and surgery.
 
You perform a detailed history and physical examination with low- complexity decision-making. You spend 30 minutes on the visit including the time it takes you to prepare the report back to the surgeon. Which CPT and ICD-9 code should you use for the encounter?

North Carolina Subscriber

Answer: You should report the visit with 99243 (Office consultation for a new or established patient) linked to 382.3 (Unspecified chronic suppurative otitis media). The encounter qualifies as an office consultation. Here's why:

 1. Another physician requests your opinion on the patient's suitability for surgery.
 2. You perform an evaluation in response to the surgeon's request.
 3. You issue a written report of your findings to the requesting physician.

The office consultation qualifies as a level-three office consultation. You perform a detailed history, detailed examination and low-complexity medical decision-making. Even though you spend less time than physicians typically spend on the visit - 30 minutes instead of 40 minutes - the visit still qualifies as 99243. You perform all three components that 99243 requires.
 
To explain why you see the patient, you should report the OM diagnosis (382.3). You are clearing the patient for surgery necessitated by this condition.

 - Answers to Reader Questions and You Be the Coder provided by Victoria S. Jackson, CEO of Southern Orange County Pediatric Association in California; Richard Tuck, MD, FAAP, a member of the American Academy of Pediatrics national committee on coding and nomenclature; and Lisa C. Wood, office manager at the Cancer Center of the Piedmont in Danville, Va.