Pediatric Coding Alert

Question: To use a consultation code, a coworker thinks we should make sure the requesting physician also documented his request. Is this a consultation requirement?


California Subscriber
Answer: Coding experts have always suggested that the requesting physician's chart should refer to the consultation request. But no formal policy has made this a consultation requirement until now.

The change: Medicare recently stipulated that a consultation also requires documentation in the requesting physician's chart. Originally, CMS stated that the consultant had to document in the patient's medical record the "request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service)." But MedLearn Matters article 4215 also adds that this documentation must be "included in the requesting physician or qualified NPP's plan of care in the patient's medical record."

The impact: Although not required in CPT, anticipate that private payers may adopt Medicare's new requirement and expect a properly documented request to include substantiation by the requesting physician. To protect your consultation payments, create a form that you can fax to the requesting physician for him to file in the patient's chart. Taking this step won't ensure that the requesting physician will file the paperwork, but it increases the chances that documentation appears in the chart. Expect to see similar forms sent to you when the pediatrician serves as the requesting source.

Example: An oral surgeon requests a pediatrician make sure a patient with a heart murmur is healthy enough to have impacted wisdom teeth removed. The pediatrician:

• documents that she is seeing the patient on the request of Dr. Surgeon to make sure the child is clear for oral surgery

• performs an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making

• faxes a copy of her findings and a "Verification of Request" form stating that Dr. Surgeon requested Dr. Pediatrician's opinion on Patient A's suitability for wisdom teeth removal. You code a level-two consultation as 99242 (Office consultation for a new or established patient ...) and sequence using ICD-9 guidelines V72.83 (Other specified pre-operative examination), 520.6 (Disturbances in tooth eruption) and 785.2 (Undiagnosed cardiac murmurs). Because you have made every effort to substantiate the service's three R's--request, render and report--and have clear documentation of your role, your consultation charge should pass an auditor's scrutiny.

Download the Medicare consultation service instructions from www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4215.pdf.