Pediatric Coding Alert

Question: An emergency department (ED) physician requested that a pediatrician see a patient. Should I use CPT 99242 as the procedure code?


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Answer: No universal rule applies to reporting pediatrician services to an ED patient. You may code an outpatient consultation (99241-99245), an outpatient office visit (99201-99205 or 99212-99215), or an ED service (99281-99285), depending on the encounter's circumstances.

If the ED physician made a formal request and the pediatrician sent a report back to the ED doctor, you should report a consultation (99241-99245, Office consultation for a new or established patient ...). This means the ED physician asked for the pediatrician's opinion and the pediatrician did not completely assume patient care.

Often, however, an ED doctor may call a pediatrician because the ED doctor isn't familiar with children and chooses not to examine the patient. In this case, you should use an ED code (99281-99285, Emergency department visit for the evaluation and management of a patient ...).

Example: Your after-hours office protocol is for patients to go to the ED. The ED physician contacts your office and asks your pediatrician to see the patient. The pediatrician comes in and treats the patient in the ED. You should report an ED service code (99281-99285) as long as the ED physician has not examined the patient.

Watch out: If the ED physician sees the patient and the pediatrician later assumes care with total management, you should instead use outpatient new (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) or established (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient) office visit codes.