Inpatient pediatric consults

[tammym7797]

Do pediatric consults (inpatient) get paid by most insurance companies? What if a pediatrician is consulted to hospital and only monitors IV antibiotics and fluids on a child, can the pediatrician charge 96365 and not a consult code?

 

[lbermudez@mms-ms.com]

Did you try codes 99251-99255 . Those are initial inpatient consultations. Make sure to add a modifier 25 on the E&M.

 

[Cynthia Hughes]

Do pediatric consults (inpatient) get paid by most insurance companies? What if a pediatrician is consulted to hospital and only monitors IV antibiotics and fluids on a child, can the pediatrician charge 96365 and not a consult code?

There are still some health plans that pay for consultations (inpatient and outpatient). It is necessary to confirm the health plan's reimbursement policy for consultations prior to billing. Though this takes extra effort on the part of coders/billers, the difference in payment adds up making it worthwhile. Be sure that there is a request for advice or opinion (not a request to assume management) and a documented consultation giving that advice or opinion in the inpatient medical record. If the pediatrician assumes management/treatment of a condition after the consultation, subsequent hospital care is reported for continuing E/M services.

It would not be appropriate to report 96365 in lieu of the consultation. CPT states, "Codes 96360-96379, 96401, 96402, 96409-96425, 96521-96523 are not intended to be reported by the physician in the facility setting."

I hope that helps.
Cindy