Practice Management Alert

Question: There is some confusion in our pediatric practice on how to submit a claim for a consult code since the payers we bill do not accept the consultation codes anymore. For example: If a parent comes in our office to discuss ADHD with the provider and the patient is not present, can we submit a claim using an E/M code? There is some debate if this type of visit qualifies for reimbursement if the provider is not seeing the patient face to face. An auditor advised against billing an E/M unless the patient is present with the parent. Is that correct?

Colorado Subscriber

Answer: When your pediatrician meets with a patient’s family to discuss a condition such as attention-deficit hyperactivity disorder (ADHD) and the patient is not present, you can still report an established patient E/M code. All E/M codes represent an encounter with the patient and/or the family, as advised in CPT®. As the descriptor for these E/M codes says, the visits in this category can involve time “with the patient and/or family.”

Most likely, you will report this service based on time because the provider spends more than 50 percent of the encounter on counseling and coordination of care. In fact, a meeting with the patient’s parent is likely 100 percent counseling.

If your provider’s documentation meets the following three criteria, you should report the appropriate E/M code (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) based on time:

• Notation of the total time spent on the encounter
• Notation of the total time spent on counseling and/or coordination of care or the percentage of the visit spent on counseling/CoC
• The reason for/topic of the counseling/CoC.