Pediatric Coding Alert

Question: A school nurse or teacher asks a pediatrician for an opinion on a child, and the physician sends a report to the requesting service. Pediatric Coding Alert 2007 Vol. 10, No. 8 suggests reporting the visit as a consultation if the physician performs and documents this service's other requirements. Most of the compliance officers I have spoken with say that this coding recommendation is erroneous or misleading.


Kansas Subscriber
Answer: The advice is correct pursuant to CPT. CPT defines a consultation as "a type of service provided by a physician whose opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician or other appropriate source."

CPT guidelines do not specify nor restrict the other appropriate source, the American Academy of Pediatrics (AAP) indicates. Examples of appropriate sources might be a school nurse, physician extender, insurance company, lawyer or a physical, speech or occupational therapist, according to the AAP article "Consultation or Referral?" available at http://practice.aap.org/content.aspx?aid=1284. CPT offers these examples: physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer or insurance company.

Beware: Don't report consultation codes (99241-99255) for a "consultation" initiated by a patient or family, CPT instructs. For opinion requests from parents, you should instead use a nonconsultation E/M service code, such as 99201-99215 (Office or other outpatient visit ...).

Problem: CMS limits the requester to a physician or qualified nonphysician practitioner (NPP), subject to state restrictions. "The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient's medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP," according to Medicare Claims Processing Manual, Pub.100-04, Chapter 12, Section 30.6.10. Because a school nurse (RN) and teacher are not NPPs, a request for opinion from these individuals does not meet CMS' consultation criteria. 

Your compliance officers may be basing their recommendation on adhering to CMS' stricter rules, rather than CPT guidelines. To keep standards uniform, the compliance officers may advise you to follow CMS protocol regardless of insurer policy.

For instance: Children's University Medical Group's (CUMG) consultation billing and documentation policy, which limits the requester to a physician or qualified non-physician provider, states, "CUMG documentation standards include the Medicare standards. CUMG applies a uniform documentation standard to all services but bills in accordance with specific payer requirements."

Remember: To use 99241-99245, you must meet all consultation requirements including a written report back to the requesting source. Coding experts discuss the different consultation source regulations in "Capture More for Consult Without Raising Payers' Ire," Pediatric Coding Alert 2007 Vol. 10, No. 10.