Pediatric Coding Alert

Question: We have a nurse practitioner (NP) who specializes in lactation consulting. Pediatricians in the same group sometimes ask her to perform a consultation. In a "group" comprised of physicians with different specialties, a physician in the same group can request a consultation regarding his specialty. Can we report the NP's visits as consultations, provided they meet the requirements for request for opinion, render of findings, and report to the requesting source?

Massachusetts Subscriber

Answer: Whether your NP can report a consultation depends on whether the insurance company credentials NPs, as well as your state's and payers' limitations. To report a consult, NP must report 99241-99245 (Office consultation for a new or established patient ...) under her own provider number, not incident to a physician.

When a physician requests an opinion from a same-specialty non-physician practitioner (NPP), such as an NP or physician's assistant (PA), payers may not pay the consultation (99241-99245). Educational level always trumps a special training course, and a medical doctorate (MD) by definition requires more education than a PA or ARNP degree.

On the other hand, a request for consultation to a NP who has additional training, ideally a certified lactation consultant (International Board-Certified Lactation Consultant, or IBCLC) would meet the guidelines of consultation within the same group based on recognized subspecialty experience.

For an NPP in a different specialty from the requesting physician, the insurer may pay for the consult. Insurers will probably not pay for a consult by a PA, because the degree requires less training than an ARNP degree, and PAs are required to have a supervised relationship with the associated physician.

An NP, however, can ask another NP for a consultation when they are in the same specialty and the "consultant" has higher training or expertise in the problem.

If the consultation option isn't available (either due to state law or if your insurer stopped paying consults when Medicare stopped several years ago), you can always report a standard office visit for the NP's services (99201-99215). This is more readily recognized if provided on a different date of service, again billed under the NP's NPI, not under incident-to guidelines to the physician.