Pediatric Coding Alert

Question: An established patient who was about to undergo a tonsillectomy presented to our office for a pre-operative clearance exam. Which code should we report to her Medicaid insurer for this visit?

Ohio Subscriber

Answer: Ideally, you should report a consult code from the 99241- 99245 series for the visit. However, starting in 2010, Medicare discontinued recognition of the consult codes, which pay 40 percent more than other E/M codes that have comparable levels of history, physical exam and medical decision-making. If your Medicaid provider is following this policy, then use an E/M code (99201- 99215) for the visit and the appropriate V code for the preoperative exam (V72.81-V72.85). Listing the reason for the surgery as the primary code (and the V code as the secondary code) can be helpful with some payers.

For instance, if your Medicaid program is not recognizing consultation codes, you might report 99213 for the visit, linked to V72.83 (Other specified preoperative examination) and 474 (Chronic tonsillitis) as the diagnosis codes.

Note that consult codes do appear in CPT® 2012, so payers that accepted the codes in 2010 and 2011 may still recognize them for payment.