Pediatric Coding Alert

Question: Specialists keep faxing our office consultation confirmation forms for us to complete when we send them a patient. Do we have to take the time to do this?

Alaska Subscriber

Answer: If you understand these forms' purposes, you might be able to reduce the time you spend on them.

For coding and auditing purposes, the specialists need you to indicate the reason the pediatrician is sending them the patient. The visit's intent means the difference between the specialist correctly charging a higher-paying consultation code (99241-99245, Office consultation for a new or established patient ...) or a lower-paying office visit code (99201-99215).

If your pediatrician is requesting the specialist's opinion on a patient, the service can meet a consultation's reason and request criteria, which an auditor may look for in the patient's chart. But if your pediatrician transfers care of the patient to the specialist, the specialist should use an office visit code or risk repayment requests.

Example: A pediatrician sends a patient with chronic tonsillitis (474.00) to an ENT and requests his opinion on continuing conservative antibiotic treatment versus surgical tonsillectomy. Because you asked his opinion and expect a treatment strategy report, the encounter could qualify as a consultation.

But suppose the patient has 3+ tonsils that are interfering with breathing. Your pediatrician sends the patient to the ENT expecting that the specialist will admit the patient to the hospital for an immediate tonsillectomy. In this case, your physician is out of the care loop -- and the specialist should bill an office visit for his initial meeting.

Tip: A pre-emptive strike may reduce the volume of consultation request faxes that your office receives. Copy a specialist's form as a template, and send a completed form with each patient you send to a specialist.

Always use the term "request" and not "referral." Medicare guidelines state that the term "referral" presumes the accepting physician will totally assume care and the visit will not qualify as a consultation.