Don't have a TCI SuperCoder account yet? Become a Member >>

Regular Price: $24.95

Ask An Expert Starting at $24.95
Have a medical coding or compliance question? Don’t sacrifice your valuable time to endless research. Choose Ask an Expert to get clear answers from the TCI SuperCoder team. And here’s a tip for the budget-conscious: Select the 12-question pack to get the best rate per question!

Browse Past Questions By Specialty

+View all

Can a pediatrician bill a consult code `99242`?

Bernadette Posted Fri 02nd of August, 2013 19:46:03 PM

Hello,

A patient comes in for an ADHD evaluation. Can a pediatrician bill a CPT code 99242 if he spends 30 minutes with the patient face to face?

SuperCoder Answered Mon 05th of August, 2013 04:32:05 AM

Hi,

Attaching you a beautiful article from our own coding alert article:

Sometimes pediatricians are summoned to the emergency room because they know their patient and the family best. Or, the emergency department (ED) physician may not be experienced with children. Or, there may be some pediatric implications that the emergency physician wants some assistance with.

The biggest problem for pediatricians seems to be getting reimbursed for meeting the family in the ED, says Daniel Leviten, MD of Lakeside Pediatrics, a four-pediatrician practice in Lakeland, FL, who posed that exact question to PCA.

Leviten has hit a nerve, according to Laura Perry, coding analyst for Pediatric Surgical Associates, a six-physician group in Fort Worth, TX. We have been back and forth on this, says Perry. Our doctors are on call, but theyre not ED doctors. Formerly, when her pediatricians went to the emergency room, and the patient was not admitted, they coded an office consultation. But the place of service didnt match the code (since the visit didn't occur in their office), says Perry. So now were coding it as an ED visit (99281, 99282, 99283, 99284, 99285). Sometimes they go there to see a patient for abdominal pain, and then send the child home. The fact is, says Perry, that the reimbursement was greater for a outpatient consult. But we had to appeal every one of them (consult codes), so our office manager told her doctors to just use the ED codes, adds Perry

Perrys instincts were correct, and the insurance carriers who arent honoring the consultation codes are wrong. It doesnt matter where the pediatrician sees the patient -- emergency department or office. If the ED physician requests that you see a child there, you should use the consultation codes. The only time the pediatrician should use the ED codes is when he or she is the only physician taking care of the child -- one of those rare situations when the pediatrician says Ill meet you there and he or she is the first physician to see the patient. Otherwise, usage of the consultation codes is correct.

If, by the end of the day on which the child went to the ED, the child has been treated and discharged, you should code for an outpatient consultation (99241, 99242, 99243, 99244, or 99245). If the child is admitted that same day, you have a choice: you can code for an inpatient
consultation, or an admission.

In the adjacent column are the ED and consultation codes. Note that all of the ED codes include counseling and/or coordination of care with other providers or agencies...consistent with the nature of the problem(s) and the patients and/or familys needs.

Emergency Department Codes

CPT 99281 - requires a problem-focused history, a problem-focused examination, and straightforward medical decision-making. (Example: Uncomplicated suture removal.)

99282 - requires an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity. (Example: Child presenting with impetigo localized to the face.)

99283 - requires an expanded problem-focused history, and expanded problem-focused examination, and medical decision-making of moderate complexity. (Example: Well-appearing 8-year-old with fever, diarrhea and abdominal cramps, tolerating oral fluids and not vomiting.)

99284 - requires a detailed history, a detailed examination, and medical decision-making of moderate complexity. (Example: 4-year-old child who fell off bike sustaining a head injury with brief loss of consciousness.)

99285 - requires a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. This code is usually used when there is an immediate significant threat to life or physiological function. The three required components are to be performed within the constraints imposed by the urgency of the patients clinical condition and mental status. (Example: Previously healthy young adult patient injured in an automobile accident and brought to the ED immobilized and has symptoms compatible with intra-abdominal injuries or multiple extremity injuries.)

Outpatient Consultation Codes

99241 - requires a problem-focused history, a problem-focused examination, and straightforward medical decision-making. The typical time spent with the patient and/or family is 15 minutes.

99242 - requires an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making. The typical time spent with the patient and/or family is 30 minutes.

99243 - requires a detailed history, a detailed examination, and medical decision-making of low complexity. The typical time spent with the patient and/or family is 40 minutes.

99244 - requires a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity. Typical time spent with patient and/or family is 60 minutes.

99245 - requires a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. Typical time spent with the patient and/or family is 80 minutes.

I hope this must have helped you.

Thanks,

Bernadette Posted Mon 05th of August, 2013 12:52:46 PM

I am a little confused. So, when a patient comes in our office, a private pediatric practice (NOT an ED), for an ADHD evalutaion and we spend 30 minutes with the patient and/or family, we can bill a CPT code "99242. Is that correct? Is it safe to say that consult codes are not limited to specialists, that a primary PCP can use consult codes?

Bernadette Posted Wed 21st of August, 2013 09:47:33 AM

Hello,

We have not received a response from our last inquiry for this question. Please advise.

Thank you,

SuperCoder Answered Wed 21st of August, 2013 10:05:38 AM

Yes, a primary PCP can use consult codes, as long as you meet the requirements of a consultation (request from another practitioner, full report back to that practitioner after the exam). So 99242 would be billable if you spent 30 minutes and met the requirements of a consult (above) AND documented the total time of the visit (30 minutes) as well as the time spent counseling/coordinating care and what was discussed. If you didn't spend at least 50% of the visit counseling/coordinating care, then you have to bill based on the elements in 99242 (history, exam, and MDM).

If you didn't meet the elements required of a consult (request, exam, and report back to the requesting doctor), then bill a problem-focused E/M code (99201-99215). You can bill it based on time if counseling/coordination of care makes up 50% of the visit and you document the total time spent, the time counseling/coordinating care, and what was discussed.

Related Topics