Pediatric Coding Alert

Question: Our pediatrician wrote in the documentation, "Performed consultation with well child and her mother." We are considering reporting 99242. Does that code describe a well visit or a sick visit?

Answer: The term "consult," from a coding standpoint, refers to your pediatrician's work performing an exam at the request of another physician, and offering his opinion in writing back to that physician. You would never use a consultation code for a well child visit.

If your physician uses the term "consult" in his documentation, you must determine whether he performed a standard office visit with a patient (which some pediatricians refer to using the term "consult") or whether a true consultation based on the E/M definition was performed.

Here's the difference: To report a code from the consultation series 99241-99245, another practitioner or other appropriate source has to request your pediatrician's opinion on a particular issue that the patient is having, and your physician must perform and document an evaluation of the patient. Then the pediatrician must write a report to the requesting physician that outlines his or her findings, according to CPT®. If a specialist merely sends a patient to you and asks you to assume the patient's care, then you cannot report a consult. You must be rendering an opinion at the request of another physician or other appropriate source, and co-managing the patient. Keep in mind that the "other appropriate source" is never the patient or the parent--in that scenario, you should always use new or established patient office visit codes.

Keep in mind: CMS stopped recognizing consultations in 2010; therefore, most Medicaid programs will not accept these codes, and some other private payers have followed suit. However, the codes are still listed in CPT® 2011 (and will appear in CPT® 2012), so if a specialist referred a patient to your practice for your pediatrician's opinion, even if they are an established patient, you can report a consult code as long as you meet the requirements.

In your case, since it sounds like your physician just performed a well child visit, you will instead report a code from the 99381-99394 series to reflect that.