Pediatric Coding Alert

Question: We have a pediatrician who specializes in international adoptions. When a family receives information about an adoptee candidate, the pediatrician meets with the parents. The physician spends an extensive time reviewing the candidate's medical record and advising the parents on medical considerations. Is there any way we can report these visits?

California Subscriber

Answer: Because counseling will dominate these encounters, the pediatrician could report an office visit or consultation based on time. When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (face-to-face time in the office), the physician may consider time the controlling factor to qualify for a particular level of E/M service, according to CPT's E/M services guidelines. Consider the parents the patients, and bill the mother or father's insurance.

Catch this: If a professional source, such as the adoption agency, requests your pediatrician's opinion on the adoptee candidates' medical condition, and the pediatrician documents the request, reason and her discussion/recommendation and sends a written report to the adoption agency, you should code a preadoption consultation with 99241-99245 (Office consultation for a new or established patient ...). If the adoption agency requests the encounter for an administrative purpose, you could use V68.89 (Encounters for administrative purposes; other specified administrative purpose; other).

Otherwise, report an office visit (99201-99215, Office or other outpatient visit). For the ICD-9 code, you can use V65.19 (... other person consulting on behalf of another person).

"Most insurance policies don't reimburse much for 'adoption evaluations,'" according to Children's Hospital and Research Center Oakland. "While an HMO plan often does not reimburse, a PPO plan may provide some reimbursement."

Best bet: Check with your major payers and consider billing the patient for noncovered services.