ED Coding and Reimbursement Alert

Question: The doctor is called into the hospital to dilate a trachea site, small tube already in place, no cuff, needs cuff trachea tube to ventilate the patient. Is this a consult charge or prolonged service? He spent 45 minutes with the patient.

Gwen Cottelese
Wyomissing, Pa.

Answer: To meet the criteria for reporting consultations, the documentation must clearly indicate the referring physicians request for the consultation. After the consultation has taken place, a written report must be sent to the referring physician with the findings of the consultation.

Codes 99241-99245 are used to bill for consultations performed in the physicians office or outpatient or other ambulatory facility. Initial inpatient consultations are billed using 99251-99255. Follow-up inpatient consultations are billed using 99261-99263. Confirmatory consultation codes would not be appropriate for the example given in the question.

Prolonged service codes are used when a physician renders care to a patient, and the patient face-to-face contact is beyond the usual service in either an outpatient or inpatient setting. To meet the criteria for reporting prolonged services, the physician must have spent at least 30 minutes more in face-to-face contact with the patient than the typical time assigned to the evaluation and management code being billed for the particular service.

Prolonged service code 99354 may be billed only in addition to 99201-99215, 99241-99245 and 99301-99350. Inpatient prolonged service code 99356 may be billed only in addition to 99221-99233, 99251-99255 and 99261-99263.

In the example given, try to find an appropriate CPT code for the actual procedure performed instead of billing for a consult or prolonged service. Did the performing physician also insert the initial tube? The physician should review codes 31615 (tracheobronchoscopy through established tracheostomy incision) and 31730 (transtracheal [percutaneous] introduction of needle wire dilator/stent or indwelling tube for oxygen therapy).

If neither of these codes accurately describes the procedure performed, 31899 (unlisted procedure, trachea, bronchi) would be used. When billing an unlisted procedure code, always include a copy of the operative report.

The source for this Reader Question is Cindy McMahan, CPC, SVA Consulting, Albany, Wis.