Pediatric Coding Alert

Question: A pediatrician saw a patient whom our pediatric group never previously treated in the emergency department (ED). During the encounter that we billed as a consultation, the pediatrician told the patient to follow up with an office visit in two weeks.

At the outpatient service, the pediatrician performs a full history, physical and exam. Should I bill a new patient office visit?


Ohio Subscriber


Answer: No. You should report the follow-up outpatient service as an established patient office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...).

Why: The patient meets CPT's definition of an established patient. "An established patient is one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years," states CPT's E/M guidelines.

In your scenario, the pediatrician provided face-to-face professional services to the patient within the past three years, within the past two weeks to be exact. Therefore, you should bill 99212-99215, not 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...).

The place of service doesn't affect the patient's status. CPT differentiates a new patient from an established patient based on whether the patient received face-to-face professional services from the physician. The definition doesn't distinguish between locations. So the fact that the first service occurred in the ED and the second E/M took place in the office doesn't impact the patient's status.

Tip: You don't have to determine a patient's status when reporting an ED visit (99281-99285, Emergency department visit for the evaluation and management of a patient ...) or consultation (99241-99255). Codes 99241-99255 and 99281-99285 don't distinguish between new and established patients.

Watch out: Double-check your initial visit coding. If your pediatrician provided all of the patient's care in the ED, you should bill the service as an ED visit, not as a consultation.

For you to report an outpatient consultation (99241-99245, Office consultation for a new or established patient ...), the ED physician would have had to request the pediatrician's opinion, and the pediatrician would have had to render his findings and report them in the patient's medical chart. The ED physician would then provide the pediatrician's recommended care.