Pediatric Coding Alert

Question: After a mom had seen three other physicians for a patient's unresolved thrush and recurrent upper respiratory infections (URI), the parent requested an opinion from our double-certified internist and pediatrician who diagnosed the new patient with geographic tongue and poor eating habits including a low protein diet. The mom plans on remaining with our practice. The physician wants me to code this as a second opinion. Is there an E/M code for second opinion?

Alabama Subscriber

Answer: CPT no longer contains codes for second opinions or confirmatory consults including requests for opinions from a patient. You would instead use an office visit code (99201-99215, "Office or Other Outpatient Visit") linked to the definitive diagnosis code(s), such as geographic tongue (529.1) and/or feeding difficulties and mismanagement (783.3), other nutritional deficiency (269.8), and/or dietary surveillance and counseling (V65.3).

Tip: If the total counseling minutes comprise more than 50 percent of the physician-patient face-to-face time, you may select the E/M code based on time. Before doing so, make sure documentation indicates the total face-toface minutes, the counseling minutes, and a brief summary of the discussion topics.

If one of the original physicians, rather than the patient's parent, had requested your internist-pediatrician's opinion on the patient's unresolved thrush (112.0) and recurrent URIs (such as 465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site), the visit would have qualified as a consult (99241-99245, "Office or Other Outpatient Consultations"). The internist-pediatrician would have also had to render his findings and send a written report back to the requesting physician.

Because a request for a confirmatory consultation comes from a patient, not a qualified health care provider, CPT 2006 deleted the codes, and instructed providers to instead report the appropriate E/M code. Prior to 2006, you could describe a second/third opinion request on the necessity or appropriateness of a previously recommended medical treatment or surgical procedure with a confirmatory consult code (99271-99275).

Don't miss: If a third party requests a second opinion -- for example, to confirm that recommended treatment/surgery is medically indicated -- CPT indicates you should append the office visit code with modifier 32 (Mandated services). Not all payers, however, accept modifier 32.