Primary Care Coding Alert

Question: May a provider bill insurance for a consultation that a school nurse or teacher requests?

Michigan Subscriber

Answer: Many experts restrict an appropriate source for 99241-99245 (Office consultation for a new or established patient -) to a physician using Medicare's definition, not CPT-s. Practices that follow Medicare guidelines across the board for compliance reasons may limit the consultation accordingly to a request from a physician (or nonphysician provider [NPP]) to another physician, based on the consultation rules in section 30.6.10 of Chapter 12 of the Medicare Claims Processing Manual (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf). These rules sometimes refer to "other appropriate source[s]." In other instances, they refer only to the requesting physician or NPP.

CPT's consultation guidelines, however, offer no definitive definition of an appropriate source, other than that a request from the patient or family does not count. The guidelines give some ideas of other appropriate sources, with "e.g." (meaning "such as"): a "physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer, or insurance company."

A nurse or teacher requesting a physician's opinion on whether a child has attention deficit disorder (ADD) or attention deficit-hyperactivity disorder (ADHD) and may be a candidate for medication, which may help the child perform better in class, pay attention, be less disruptive, etc., could qualify as a consult, according to the American Academy of Pediatrics. The physician would render his findings and in his report back to the teacher or nurse detail his recommended course of treatment, including at-school medication regimens and discipline techniques. The E/M service would meet CPT's consultation requirements including requesting of opinion, rendering of services and reporting back to the requesting party.

Best bet: Check with your major payers to see whether their policies restrict a consultation's requesting source as Medicare does. The definition does not have to apply to Medicaid.

Glitch: When completing the CMS-1500 form's "requesting physician" field, whose number do you enter? Because a nurse or teacher is ineligible for a provider number, you cannot complete this field, causing an insurer to reject the claim.