Pediatric Coding Alert

CPT Codes 2006 eliminates 99271-99275 with ambiguous language

In 2006 when your pediatrician confirms another physician's opinion on a child's treatment, you will no longer use a confirmatory consultation to describe the service.

CPT 2006 will delete confirmatory consultation codes 99271-99275 (Confirmatory consultation for a new or established patient ...). Pediatric coding experts hope the AMA at its fall meeting will direct coders on how to bill these encounters.

99271-99275 Replacement Depends on Site, 3 R's

The replacement code for 99271-99275 isn't clear-cut. A confirmatory consultation could qualify as a new patient encounter or subsequent hospital care, says Andrew Borden, CCS-P, CPC, CMA, reimbursement manager at Medical College of Wisconsin in Milwaukee.

CPT's tentative explanatory language doesn't offer a definitive answer. Depending on the site of service, these services should "be reported with the consultation or non-consultation E/M codes that are appropriate to the setting of care and consistent with the definition of consultation," state CPT's agenda notes following 99271-99275's deletion.

Translation: To determine the appropriate code, look at the encounter's site of service and its consultation qualifications. If the visit meets a consultation's three requirements--request of opinion, rendering of services, and report to the requester--you should report a consult code.

Source Could Make Some Consults OVs

A source that meets a confirmatory consultation's criteria may not count as an "other appropriate source" for an outpatient (99241-99245, Office consultation for a new or established patient ...) or inpatient consultation (99251-99255). "A confirmatory consult will probably no longer qualify as a consultation," says Donna Stewart, CPC, CHCO, coding and auditing specialist for Children's Medical Group at Children's Hospital of The King's Daughters in Norfolk, Va.

CPT permits a patient, a family member, an employer or an insurer to request a confirmatory consult. "But CPT does not consider a parent an appropriate source for a regular consultation," Stewart says.

To report 99241-99245 or 99251-99255, an appropriate source, such as a physician, counselor, nurse or nurse practitioner, has to generate the request. Under current coding guidelines, "a confirmatory consultation's source would fail to meet a consultation's three R's," Stewart says. Physicians could have to report a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) instead of a confirmatory consult due to the lack of an appropriate requesting source.

Established Patient OV Will Cut Visit Payment

Giving up some confirmatory consultations probably won't affect your bottom line, if the patient is a new patient. Only new patient office visit codes 99201 and 99202 pay less than their confirmatory consult-level counterparts 99271 and 99272.

But if you have to code an established patient visit instead of a confirmatory consult, you'll lose dollars. For instance, having to replace 99273 with 99213 will cost you $38.27, based on the 2005 National Physician Fee Schedule Relative Value File.

Find Out Payer Source Requirements
 
To prepare for the confirmatory consultation code change, you should check what sources your major insurers' accept for outpatient and inpatient consultations.

Illustration: After an otolaryngologist recommends a tonsillectomy for a child, the mother asks the patient's pediatrician for a confirmatory opinion. Because a family member makes the request, your consultation coding is ambiguous.
 
Now you should report the visit as a confirmatory consult with 99271-99275. In 2006, you should verify whether the insurer considers this a consult or an outpatient new or established patient visit.

Remember: You can still use modifier 32 (Mandated services) on the E/M code. "If an insurer requests the opinion, you should indicate a mandated service with modifier 32," Stewart says.