Pediatric Coding Alert

Question: How do I know when a transfer of care has taken place?

New York Subscriber

Answer: A transfer of care typically happens in one of two ways. The Medicare Carriers Manual section 15506 defines the most straightforward instance: "A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance."
 
Transfers of care also occur when a specialist performs a consult for a pediatrician and, after examining the patient, suggests that she should follow the patient for the problem instead of the pediatrician. In this case, the specialist often sends a note back with the consultation report indicating that it is her opinion that the patient should be followed by the specialist and requests permission to do so. For instance, a pediatric urologist consulting for a pediatrician on a child with an undescended testicle (752.51 ) might continue to treat the child for this problem throughout any surgical care and follow-up.
 
The consulting physician's documentation "closes the loop." The documentation also indicates that the consultation was performed at the request of the pediatrician, provides a report of her medical opinion on the patient's condition, and asks the requesting physician's permission before assuming care. Both physicians should keep this information in the patient's file.
 
If the scenario above occurs, then "the receiving physician would report a new or established patient visit, depending on the situation ... and setting (e.g., office or inpatient)," according to the MCM. If the transfer of care occurs according to the second scenario, the receiving physician can bill the initial visit with a consultation code.
 
In both cases, subsequent visits should be reported using the appropriate established or in- or outpatient codes, 99221-99223 or 99211-99215, respectively.
 
Remember that the relative value and associated reimbursements are much higher for consultations than for referrals, so a pediatrician will always want to bill for a consultations if the coding and documentation requirements are met.

  - You Be the Expert was reviewed by Richard Tuck, MD, FAAP, practicing pediatrician with Primecare Pediatrics of Zanesville, Ohio.