Pediatric Coding Alert

Question: Humana denied our claim with 99212 and diagnosis V70.3. Should we code medical clearing for surgery differently?

Wisconsin Subscriber

Answer: Because your physician is consulting with the patient and family about surgery, a better choice would be 99242 (Office consultation for a new or established patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making). You can still include V70.4 (Examination for medicolegal reasons) with documentation  explaining the encounter.

Note: Reporting consultation codes is an area of concern for some practitioners because of Medicare's decision to stop paying for the service. However, most private payers have not followed Medicare's decision and continue to pay for consultation codes at this time.

-- Answers for You Be the Coder and Reader Questions were reviewed by Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.