Pediatric Coding Alert

Question: We have a nurse practitioner (NP) who has specialized education in lactation consulting. Pediatricians in the same group sometimes ask her to perform a consultation.

In a group comprised of physicians with different specialties, a physician in the same group can request a  consultation regarding his specialty. Can we report the NPs visits as consultations, provided they meet the requirements for request for opinion, render of findings, and report to the requesting source?

New Mexico Subscriber

Answer: Whether your NP can report a consultation depends on whether the insurance company credentials NPs, as well as your states and payers limitations. To report a consult, NP must report 99241-99245 (Office consultation for a new or established patient &) under her own provider number, not incident to a physician.

When a physician requests an opinion from a samespecialty nonphysician practitioner (NPP), such as an NP or physicians assistant [PA]), payers usually will not pay the consultation (99241-99245). Educational level always trumps a special training course, and a medical doctorate (MD) by definition requires more education than a PA or ARNP degree.

For an NPP in a different specialty from the requesting physician, the insurer may pay for the consult. Insurers will probably not pay for a consult by a PA, because the degree requires much less training than an ARNP degree.

An NP, however, can ask another NP for a consultation when they are in the same specialty and the consultant has higher training or expertise in the problem.