Pediatric Coding Alert

2 case studies show you when to bill a telephone call, consultation and admission

If you're providing emergency department (ED) services, such as phone care, in-person opinions, and hospital admissions, you should know that CPT applies different rules to each type of care.
 
Many pediatric offices no longer routinely admit patients to the hospital. So you may not be familiar with the codes you should use when a pediatrician provides occasional off-site or on-site ED care.
 
You can correctly code the pediatrician's services if you report the encounter based on the following expert-approved case studies:

Case Study 1: Pediatrician Provides Phone Advice

The scenario: An ED physician who is treating a suicide-attempt patient calls the teen-ager's pediatrician to ask about the patient's prior mental history.

What to report: You should submit a telephone call code (99371-99373, Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other healthcare professionals [e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists] ...).
 
Common mistake: You shouldn't bill an E/M service code when a pediatrician doesn't see the patient in person.

Charge Indirect Care With Call Code

When a pediatrician only provides advice over the phone to an ED physician, you shouldn't code an ED service. "Codes 99241-99245 (Office or other outpatient consultations) require three of three key elements," says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif. The pediatrician must perform a face-to-face history, examination and medical decision-making to report a consultation.
 
But no face-to-face contact exists when a pediatrician offers telephone care. So, the pediatrician cannot perform an exam, Jackson says. Therefore, you can't meet 99241-99245's examination requirement.
 
Solution: Select the appropriate-level telephone care code for the pediatrician's work. For the conversation between the pediatrician and the ED physician, you should assign 99372 (... intermediate [e.g., to provide advice to an established patient on a new problem, to initiate therapy that can be handled by telephone, to discuss test results in detail, to coordinate medical management of a new problem in an established patient, to discuss and evaluate new information and details, or to initiate new plan of care]). You would report 99372 because the pediatrician coordinated medical management of a new problem in an established patient.
 
Tip: If the insurer denies the telephone code, you may consider billing the patient. Before you do so, make sure the payer doesn't consider 99371-99373 a nonpaid covered service, says Richard Tuck, MD, FAAP, a member of the American Academy of Pediatrics national committee on coding and nomenclature.

Case Study 2: ED Requests Pediatrician's Opinion

The encounter: An ED physician who is treating a child for severe abdominal pain calls in a pediatrician to provide pediatric-appropriate treatment recommendations.
 
Correct coding: You should assign an office consultation 99241-99245 (Office consultation for a new or established patient ...).
 
Pitfall: Don't submit 99241-99245 "if the pediatrician assumes care," Tuck says. The pediatrician, however, may provide treatment.

Use Consult for Advice-Only Encounter

You should bill a consultation when an ED physician calls a pediatrician in, as long as the pediatrician doesn't assume patient care.
 
"If, after examining the child, the pediatrician admits her to the hospital, you shouldn't use 99241-99245," Jackson says. A consultation allows the physician to treat the patient but not take over care.
 
When a pediatrician assumes care or admits a child to the hospital, you should instead report an outpatient office visit (99201-99215) or an admission (99221-99223, Initial hospital care, for the evaluation and management of a patient ...). The ED physician in these situations transfers patient care rather than requesting the pediatrician's opinion, Tuck says. "Therefore, the pediatrician completes a referral, not a consultation."
 
CPT doesn't permit you to report a consultation on the same day as a hospital admission. "If you admit the patient, you lose the consult," Jackson says. You may, however, use your consult work to "up your admission code."
 
Here's how: Combine the initial evaluation's documented history, examination and medical decision-making with the admission's key components.
 
Watch out: The Office of Inspector General is notorious for consultation scrutiny. To prevent audits on your 99241-99245 claims, make sure the ED physician notes his consultation request in the patient's medical record and that the pediatrician documents his opinion as a written report back to the ED physician, Tuck says. "This documentation completes the three 'R' (request, render, report) loop that a consultation requires."