Pediatric Coding Alert

Collect cash for your consults with these three simple steps.

It's hard to imagine a more misunderstood group of CPT^® codes than 99241-99245.

Problem: Since the 2010 Centers for Medicare and Medicaid Services (CMS) decision to deny payment for the services, and the subsequent decisions by many private payers, including United Healthcare, to follow suit, pediatric practices have been unsure about whether to use the codes to report or bill for consultation services, or whether they should not even use the codes at all.

So, if you're still confused about how to document and bill for any consults your physician may perform, read on and code accurately and confidently.

The Scenario

Your pediatrician sees a patient who suffers from frequent ear infections and sends the patient to an otolaryngologist, who determines the patient needs a myringotomy. The specialist sends the patient back to your office, where your pediatrician performs a consultation to determine that the patient is not under any great risk for being put under anesthesia and undergoing the procedure.

Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, argues that this scenario qualifies as a consult as "the patient has been sent back to the pediatrician for a specific reason. The pediatrician performs the history, exam, and the medical decision making [MDM] for a specific reason: to clear the patient for surgery at the request of the surgeon."

However, since 2010, "The Office of the Inspector General stated that it believed CMS was paying inappropriately for consultations," according to Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania. This, Falbo believes, has led to "variations in the definition of 'transfer of care,' and disagreements on how consultations are handled." In other words, any payer following CMS guidelines will not reimburse you if you use a consultation code for consultations.

To clear up the confusion, Holle and Falbo offer the following suggestions:

1) Bill for denial

If you don't know if your payer will reimburse for consults, Holle recommends "billing the consult codes when they are appropriate, and then get a denial as not a valid code." This way, she argues, "the office can decide the best way to crosswalk the code at that time. If the carrier still pays on consults, not billing them would be a loss of revenue."

2) Crosswalk

All the consultation codes crosswalk easily to new or established patient evaluation and management (E/M) codes with one exception: CPT^® 99211 (Office or other outpatient visitfor the evaluation and management of an established patient ...) is intended for services that "may not require the presence of a physician or other qualified health care professional." This level-one code, as Holle notes, is a "step down" as it is "for the nurse, not a provider." So, in the absence of a level one code for a provider, the crosswalk looks like this:

3) Use Modifier AI for Admissions

Falbo also offers the reminder that if the consult involves a patient being admitted to a hospital, you should use HCPCS modifier AI (Principal physician of record) which, in CMS's words, identifies "the physician who oversees the patient's care from all other physicians who may be furnishing specialty care." This, she advises, will "distinguish the admitting physician from the consulting physicians in the inpatient hospital setting," avoiding any confusion in your documentation and clarifying the situation for your payer.