Billing Visits for Fetal Anomalies
Published on Sat Jan 01, 2000
Pediatrics and obstetrics are by necessity closely intertwined at times, making coding and billing difficult. Take the case of a pregnant woman who is referred to you by her obstetrician (ob), who has diagnosed a fetal anomaly and wants to get your opinion on what should be done. Who is your patient, fetus or mother? How do you bill when there is no insurance (for the fetus)? And how do you satisfy the requirements of a consultation code if all you are doing is advising the mother on possible outcomes and her options?
Using Consult Codes
Lets take the last question first. The proper CPT Code for this visit is a consultation (99241-99245), but you must make sure that you are following the rules for consultations. There must be a request for a consult (from the ob). Andthis is the important part for pediatricians in this scenariothe pediatrician must document his or her opinion in the mothers medical record and communicate this opinion by written report to the ob. In other words, it is not enough just to tell the woman what the prognosis is. You must tell the ob as well.
Here is how Medicare defines the criteria for a consultation:
1. The consultation must be provided by a physician whose opinion or advice regarding evaluation
and/or management of a specific problem is
requested by another physician.
2. The need for the consultation must be documented.
3. After the consultation, the consultant must prepare a written report for the referring physician.
Tip: Because more than 50 percent of the time spent on this visit will be counseling, you can code based on time alone, notes Richard A. Molteni, MD, FAAP, a neonatologist who is a member of the CPT editorial panel.
If a pregnant woman comes to you on her own to talk about the fetus she is carrying, you cannot charge a consultation. The consultation must be initiated by another physician or other appropriate source, according to CPT, and a patient and/or family is not such a source.
Consider Both a Patient
Now, who is the patientthe mother or the fetus? Any debate is basically philosophical because you can only bill the mothers insurancethe fetus doesnt have any.
The mother and the fetus are the patient, asserts Richard H. Tuck MD, FAAP, of Primecare Pediatrics in Zanesville, Ohio. As long as the consult is requested by an ob, and the pediatrician satisfies the requirements of [...]
