Pediatric Coding Alert

Question: A patient presented for an ADHD evaluation. Can we report consult code 99242 if he spent 30 minutes with the patient face-to-face? Is it safe to say that consult codes are not limited to specialists, that a primary PCP can use consult codes?

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Answer: Yes, a primary care physician (PCP) can use consult codes, as long as you meet the requirements of a consultation (request from another practitioner, exam of the patient, full report back to that practitioner after the exam). So 99242 would be billable if you spent 30 minutes and met the requirements of a consult and documented the total time of the visit (30 minutes) as well as the time spent counseling/coordinating care and what was discussed. If you didn’t spend at least 50 percent of the visit counseling/coordinating care, then you have to bill based on the elements in 99242 (history, exam, and medical decision-making) instead of basing your visit level on time.

If you didn’t meet the elements required of a consult (request, exam, and report back to the requesting doctor), then bill a problem-focused E/M code (99201-99215). You can bill it based on time if counseling/coordination of care make up 50 percent of the visit and you document the total time spent, the time counseling/coordinating care, and what was discussed.

Example: If you’d like to know what documentation should look like when billing based on time, consider this example: The pediatrician sees an 8-year-old with ADHD for a three-month evaluation of the ADHD, and the mother also wants to discuss behavior problems. The visit would warrant 99213 based on the three elements of history, examination and medical decision-making. But after spending 10 minutes with the child, the doctor spends another 30 minutes talking to the mother. Because more than 50 percent of the time is spent on counseling, amounting to a total of 40 minutes, 99215 is warranted. You would document the visit, along with the information on time spent and what was discussed, such as “Spent 30 minutes of a total 40 minute visit discussing ADHD strategies and behavior problems with the patient and his mother.”