Pediatric Coding Alert

Question: Another facility referred a mother who suspected that someone had abused her child. The mother attended a consultation without the child present. Should I report 99401 for the visit?

Answer: No, you should instead use a consultation or office visit code. You may report 99241-99245 (Office consultation for a new or established patient ...) or 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient ...) even if the patient isn't present. Some Medicare carriers restrict E/M coverage to face-to-face patient-physician services. But private insurers, which pediatric practices typically bill, usually don't follow this requirement.

You should select the appropriate E/M code depending on the service. If the referring facility staff request your opinion and you send a report back to them, you should submit a consultation (99241-99245). When the visit doesn't meet these two criteria, you should report an office visit (99201-99215). Because counseling comprised the entire encounter, choose the appropriate-level E/M service based on time. For instance, if you spend 15 minutes discussing her suspicions, the child's behavior and warning signs, you should report 99241 for a consultation, 99201 for a new patient office visit or 99213 for an established patient problem-related visit.