Otolaryngology Coding Alert

3 scenarios test your outpatient originating admissions skills

You can rest assured that you're not double-dipping or undercoding hospital admits from other sites of service if you score 100 on this quiz. 

Because CPT doesn't contain an "admit" code, reporting hospital admissions that start in outpatient encounters can prove challenging to the most experienced E/M coder. But you can code these one- and two-day services with confidence if you correctly report these encounters:

ENT Admits an Office-Visit Patient

When an office visit results in the otolaryngologist admitting the patient to the hospital, remember to roll the outpatient service into a single inpatient code.

Question 1: A patient presents to an otolaryngologist's office for severe tonsillitis. After examining the patient, the physician decides the patient needs intravenous antibiotics. The otolaryngologist admits the patient from the office. Later that day, he goes to the hospital and checks on the patient's response to treatment. The physician determines that the tonsils have gone down, and the patient doesn't need surgery. How many codes should you report?

Answer 2: In this scenario, you should report one code for the day's E/M services. Because the physician saw the patient in the office and in the hospital later that day, you should bill only the initial inpatient visit (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...), says Rhonda Buckholtz, CPC, president of the Erie American Academy of Professional Coders chapter in Pennsylvania. Choose the appropriate level based on the history and examination that the otolaryngologist performs and documents in both encounters.

Consult Leads to Admission

Before rolling the outpatient service into 99221-99223, check which service pays more and report the higher-paying service.

Question 2: A family physician (FP) requests an otolaryngologist's opinion regarding a patient's asthma. After examining the patient and documenting a level-four consultation, the otolaryngologist admits the patient to the hospital. Later that day, the ENT re-evaluates the hospital inpatient and issues a written report of his findings to the FP. Should you submit one or two E/M codes?

Answer 2: Even though the otolaryngologist performed multiple E/M services, you should submit one code. Your E/M claim will represent the otolaryngologist's level-four consultation (99244, Office consultation for a new or established patient ...) and the same-day initial hospital care (99221-99223).

Problem: The admission doesn't reimburse as much as the consult. Code 99223 contains 4.15 relative value units (RVUs), but 99244 has 4.57 RVUs. So if you submit initial hospital care rather than an outpatient consultation, you'll lose over $15 ($170.64 - $154.96 = $15.68 Medicare 2004 national rates).

Solution: "You should charge the consult instead of the admit," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J. Before billing 99244, make sure the otolaryngologist's outpatient encounter meets a consultation's three requirements (request, render, report). "In addition, your otolaryngologist's, as well as the FP's, office and chart documentation should clearly indicate that the FP asked the otolaryngologist for an opinion," she says.

You would then start reporting inpatient codes for additional hospital care. "If the otolaryngologist performs inpatient follow-up, submit subsequent inpatient days with 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...)," Cobuzzi says.

ENT Sees Inpatient on the Next Day

Remember to separately bill outpatient-to-inpatient encounters when the otolaryngologist performs the encounters on different days.

Question 3: After evaluating an 18-year-old female with a severe ear infection at 4:30 p.m., an otolaryngologist sends the patient to the hospital to start intravenous antibiotic therapy. The physician sends the patient to the hospital, calls in the admitting orders and sees the patient the next day.

Answer 3: In this case, you should report each day's service. Submit the office visit on day one with 99201-99215. For the initial hospital care on day two, assign 99221-99223. "You should charge initial hospital visit the next day because that's when the otolaryngologist first provides inpatient care," Cobuzzi says.