Pediatric Coding Alert

Question: We have two specialists in our group, one of whom is a pediatric endocrinologist, the other specializes in behavioral pediatrics. If one of the other physicians in our group refer a patient to them for an endocrine or behavioral issue, should we use just an E/M code, or should we instead use a consult code? We have had better luck with charging out E/M codes than consult codes in our practice. 

Codify Subscriber

Answer: If your insurer allows consultations and you meet the criteria (request, exam and report back to the requesting doctor), you should report a consultation in this scenario. If you receive a denial, you can switch to the office visit codes (99201-99215) instead. Keep in mind that a consult requires you to meet all three key factors (history, exam and medical decision-making), whereas a subsequent visit only requires two of the three factors. So if you have a comprehensive history and exam, you could potentially report a 99215 instead of a 99214. 

Some carriers will change your consult code to an E/M code if they don’t accept consults. If this happens to you, make sure the payer codes it correctly and not lower than what the doctor performed and documented.