Otolaryngology Coding Alert

Let's look more closely at the first MDM element, which contains four levels - minimal, limited, multiple and extensive. At the minimum, an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) will include a diagnosis and treatment plan, Soerries says. If the otolaryngologist considers additional diagnoses or treatment options, this will raise the diagnostic uncertainty element.

Here's how to know if an office visit qualifies for a higher level: Urge your ENT to document a range of possible diagnoses and that she selected one based on the available information.

2. Watch for Additional Conditions

When your ENT treats another condition during an office visit, encourage her to list more than the primary diagnosis, says Theresa Coats, CPC, office manager at Northland Ear, Nose and Throat in Liberty, Mo. This will raise the diagnosis and management options element, which in turn may boost the level of E/M service, she says.

For instance, a male patient presents for follow-up of otitis media. During the fall exam, in which the otolaryngologist finds no infection, the patient also mentions frequent sneezing. The otolaryngologist performs a small allergy workup for suspected allergic rhinitis (477.9, Allergic rhinitis; cause unspecified). He tells the patient to return in two weeks for allergy testing.

Listing only one diagnosis, such as 382.9 (Suppurative and unspecified otitis media; unspecified otitis media), will make the visit qualify for the lowest diagnostic element: minimal. But because the otolaryngologist addresses a new problem and plans additional workup, she should report 477.9 for addressing the underlying disease. Coding the new problem with workup will boost the diagnosis and management options element from minimal to extensive.

3. Tally Diagnoses and Treatment Options

Even if your otolaryngologist chooses the diagnosis and management options element, she must explain in enough detail why she selected a particular level. Her MDM roadmap should provide you or an outside auditor with the tools necessary to check a sample of her work.

To determine or audit physician-assigned MDM levels, use a chart that awards points to the number of diagnoses or treatment options in the following manner - see top table.
 
Test yourself: Try scoring the following scenario using the above auditing tool.

DX/management scenario: Patient is a 15-year-old male established patient who returns today for a follow-up after antibiotic therapy for acute bacterial tonsillitis. After three days of phenoxymethyl penicillin treatment, his temperature has returned to normal, and he has made an uneventful recovery. But he complains of sneezing, watery eyes and nasal congestion. The otolaryngologist prescribes nasal decongestants and antihistamines for his rhinitis.

The patient's acute tonsillitis (463) constitutes an established, previously diagnosed problem that is responding to management, so it rates one point. As a previously undiagnosed problem, the rhinitis (477.9) rates three points. Therefore, with four points, the scenario qualifies as extensive.