Pediatric Coding Alert

Question: In volume 14, issue 11 of Pediatric Coding Alert, you advised a practice regarding a patient who had visited a physician six months ago, and then was referred back recently for a new condition. You advised that the patient should be billed with an established patient office visit code (99211-99215) because they had seen your physician previously within the past three years. However, it's possible that a consultation code could apply instead since another physician referred the patient back to you recently for a separate problem. Can you clarify?

New Jersey subscriber

Answer: If your payer still accepts consultation codes and your documentation meets the requirements of the consult code series 99241-99245, you should report a code from that range instead of an office visit code.

Keep in mind: CMS stopped recognizing consultations in 2010; therefore, most Medicaid programs will not accept these codes, and some other private payers have followed suit. However, the codes are still listed in CPT® 2011 (and will appear in CPT® 2012), so if a specialist referred a patient to your practice for your pediatrician's opinion, even if they are an established patient, you can report a consult code as long as you meet the requirements.

Specifically, another practitioner has to request your pediatrician's opinion on a particular issue that the patient is having, and your physician must perform and document a full exam of the patient. Then the pediatrician must write a report to the requesting physician that outlines his or her findings, according to CPT®. If a specialist merely sends a patient to you and asks you to assume the patient's care, then you cannot report a consult. You must be rendering an opinion at the request of another physician, and co-managing the patient.