Pediatric Coding Alert

Question: An established patient's mother wants to consult with our pediatrician without the child present. No physician referred her. The consultation will last more than 45 minutes. Which CPT Code should I use for the consultation?

Illinois Subscriber

Answer: You should report this service as an office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...), not a consultation (99241-99245, Office consultation for a new or established patient ...). To report 99241-99245, CPT requires another physician or other appropriate source, such as a school nurse or social worker, to request your pediatrician's opinion. In addition, the pediatrician must send a written report of her findings to the requesting party.

Although the scenario doesn't meet CPT's consultation criteria, you may report the visit based on time. When counseling accounts for more than 50 percent of a patient and/or family encounter, you should consider time the key factor in selecting the appropriate E/M service level.

In your example, the pediatrician spends 100 percent of the 45-minute visit counseling the mother about her concerns. Therefore, you should report 99215 (... physicians typically spend 40 minutes face-to-face with the patient and/or family) for an established patient.