Pediatric consultations can be a confusing coding issue. Guesswork can be eliminated or reduced with good communication between physicians and coders in clear and concise documentation. According to Current Procedural Terminology (CPT®), a consultation is a type of service provided by a pediatrician whose opinion or advice on the evaluation or management of a specific problem is requested by another physician or other appropriate source. The Centers for Medicare & Medicaid Services (CMS) clarifies the definition by saying that the consultant prepares a report of his or her findings that is provided to the requesting physician for that requesting physician’s use in treatment of the patient. A consultation may be an initial opinion or a second or third opinion. The request for a regular consultation must come from a physician or other appropriate source (eg, physician assistant, nurse practitioner, school nurse). Further confusion has also been added since as of January 1, 2010, Medicare will no longer be paying for consultation services. However, it is important to remember the following:
- Consultation codes are not being deleted from CPT nomenclature
- Consultation codes will remain on the RBRVS fee schedule with their established values
- This is a Medicare payment policy and may not be adopted by other payers
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However, if non-Medicare payers do choose to adopt this policy, it is imperative that they also make the budgetary accommodations as have been done in the Medicare program. The Medicare funds saved in not paying for consultations have been used to increase the 2010 RBRVS relative value units for other evaluation and management (E/M) codes, including the new and established office visit codes (99201-99215) and the initial hospital care codes (99221-99223). Non-Medicare payers that follow the Medicare consultation policy must also utilize the higher RVUs for these non-consultation E/M codes.
For more information on the AAP’s Position on the Medicare Consultation Policy click here.
Consultation Request Versus Referral
While a consultation is a request seeking another physician’s opinion or advice on a specific issue, a referral is a transfer of care from one physician to another for the purpose of evaluating and treating a patient for a specific problem. If after a consultation request is made, the requesting physician decides to transfer care to the consulting physician, it would no longer be appropriate for the consulting physician to report his or her services using consultation codes. All visits after the first consultation would be reported under other office or inpatient evaluation and management (E/M) codes (eg, 99211–99215, 99221–99223, 99231–99233). If, upon conclusion of the initial consultation, the consulting physician determines he/she will assume care for this issue or problem, the consultation codes may still be reported since the intent of the visit was to seek medical advice or opinion and not a transfer of care.
Why Should Pediatricians Consider Using Consultation Codes?
These codes are an alternative to other E/M codes and can establish you as an expert coder, if used in the right setting and under the guidelines of CPT. The payment is far better than most other E/M codes. The obligation of the consultant is to communicate in writing with the requesting source and recommend medical care.
Hospital Consultations
Categories of Inpatient Consultations
Inpatient consultations can be a full evaluation with recommendation (eg, a family doctor’s patient with significant chronic pneumonia) or specific problem management (eg, a surgeon asking your opinion for fluid management on a child postoperatively).
Newborn consultations can be for a normal newborn who was referred from the family doctor or a newborn for whom there are recommendations for medical advice and management. Many times, for an infant who is seriously ill or premature, under the care of a neonatologist, and soon to go home, the neonatologist may require a consultation by the pediatrician so the pediatrician can become familiar with the patient prior to the patient coming to the pediatrician’s office.
Another type of consultation actually takes place prior to a baby being born; for example, a pediatrician is asked to consult on the behalf of an obstetrician on a mother whose fetus has already shown medical conditions such as hydrocephalus or hydronephrosis.
In this particular case, the consultation would be on the mother’s chart, and the pediatrician would be billing the mother’s insurance as a consultant and sending the report to the obstetrician.
The initial inpatient consultation codes (99251–99255) are to be used only once by the reporting physician for the admission. For follow-up visits, regular subsequent E/M codes (hospital, 99231–99233; nursing facility, 99307–99310) are used, even for a completely different problem during the same hospitalization. The consultant also should use subsequent hospital codes if the attending physician wants the consultant to provide ongoing management of one condition (eg, heart failure) while the attending physician provides ongoing management of the other active conditions. It is important to use proper and different International Classification of Diseases, Ninth Revision, Clinical Modification codes linked to the CPT code. For proper documentation of consultation code levels, please refer to Coding for Pediatrics.
Emergency Department Consultations
Many times, someone from a hospital emergency department (ED) will ask a pediatrician to consult on a patient who is not that doctor’s patient because he or she is the on-call doctor at the time. The pediatrician is asked to consult from the ED, and is actually the only doctor to see the patient. The patient can certainly be seen prior to the pediatrician’s visit by the ED physician. Many times, an ED physician will be seeing a pediatrician’s patient and then consult with that pediatrician after having seen the patient. Because the ED physician is using E/M codes for the ED, the pediatrician would need to use consultation codes, even though this is the pediatrician’s own patient. If the ED physician evaluates and sees the patient in the ED and then sends the patient to the pediatrician’s office and transfers total care, this would be a reason to use office E/M codes and not consultation codes. If the pediatrician is seeing the patient in the ED and no one asked for a consultation, the pediatrician would need to use E/M ED codes 99281–99285. If, after consultation, the patient is admitted to the hospital, the ED codes are no longer used—instead, hospital admission codes such as 99221–99223 are used.
Outpatient Consultation
Sources of consultations: Outpatient consultations need to be physician requested or initiated by another party. This may be done by schools or insurance agencies. Codes for confirmatory consultations have been deleted. If you are seeing patients for follow-up visits, it is recommended to use office E/M codes (99212–99215).
Consultations from medical personnel: Codes 99241–99245 are used for new and established patients. This can be your own or another physician’s patient and can come from a variety of sources.
Remember the 3 Rs of consultations.
- Request for opinion or advice; must be documented in the medical record.
- Render an opinion (reason); any service ordered or performed must be documented.
- Respond with opinion; findings must be communicated to the requesting physician in writing. Include the letter in your chart.
Payment with consultation codes versus office E/M codes may increase anywhere from 25% to 50%, depending on the insurance company.
Modifiers Used in Consultations
- Modifier 25 may be used when a significant, separately identifiable E/M service by the same physician on the same day of a procedure or another service is performed.
- Modifier 57 may be used if a decision to perform major surgery is made during the consultation. This particular modifier would be used by a pediatric surgeon, not by a pediatrician.
Here is an important National Provider Identification reminder. Anytime a pediatrician performs a service for a patient at the request of another physician, the consultant must indicate the requesting physician’s name (Block 17) and ID number (Block 17a) on the CMS 1500 claim form.
What happens when a pediatrician asks another pediatrician in the same group to consult? The CMS will pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all the requirements for the use of the CPT consultation codes are met.
There are a variety of ways that a pediatrician can code using consultation codes, especially in the care of children with special health care needs. Unfortunately, pediatricians underuse this means of coding and are paid at a lower rate. Hopefully, these tips will help you in your practice.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.