Pediatric Coding Alert

Question: A pediatrician counsels a patient's parent for an hour regarding the child's school and behavior problems. The patient isn't present. How should I code the visit and diagnosis?
Tennessee Subscriber


Answer: You should code the encounter as CPT 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) or 99215 appended with modifier -21 (Prolonged E/M services) linked to V65.19 (Other person consulting on behalf of another person).

E/M: Even though the patient is not present for the visit, you may still use an E/M code. When reporting based on time, CPT counts face-to-face time as "that time the physician spends with the patient and/or family" (emphasis added).

Since counseling accounts for more than 50 percent of the encounter, you will be using time as the key factor in selecting the appropriate E/M service level. Therefore, CPT doesn't require the patient's presence to code the encounter.

In your example, the pediatrician spends 100 percent of the 60-minute visit counseling the mother about her concerns. So, you should assign 99215 (... physicians typically spend 40 minutes face-to-face with the patient and/or family) based on time. CPT suggests that physicians usually spend 40 minutes on a level-five established patient office visit.
 
You could consider appending modifier -21 to 99215. The amount of face-to-face time (60 minutes) exceeds 99215's 40-minute suggested time allotment. However, this 20-minute difference doesn't meet the 30 minutes necessary to bill a prolonged service code (+99354 and +99355, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service ...). Therefore, modifier -21 would be appropriate.

Problem: Some payers may require you to submit a report with the claim, explaining why the circumstances required extra time and why the encounter warrants modifier -21.

ICD-9: For the diagnosis, you should use V65.19. The V code describes a person seeking advice or treatment for a nonattending third party.

You may also code the reason the person is seeking advice. If the pediatrician or another physician hasn't diagnosed the patient with a specific problem, look at using a V code, such as V40.0 (Problems with learning) or V40.3 (Other behavioral problems).

Insurers may not reimburse the visit due to mental- health carve outs related to the V40.x diagnoses. Alternatively, payers may deny the counseling diagnosis.