Otolaryngology Coding Alert

Start bulletproofing your modifier 25 service documentation

Throw away your notes on distinguishing follow-up consultations from initial consults--CPT 2006 eliminates this distinction.

The AMA released the tentative agenda for its CPT 2006 Coding Symposium, to be held Nov. 17 and 18 in Chicago. The agenda offers the first official clues as to which big coding changes you can look forward to next year. When the 2006 CPT updates take effect Jan. 1, 2006, otolaryngologists will face two major E/M changes. CPT 2006 will:

- delete follow-up inpatient consultation codes (99261-99263, Follow-up inpatient consultation for an established patient -) and confirmatory consultation codes (99271-99275, Confirmatory consultation for a new or established patient -)

- clarify modifier 25's explanatory text to specify that documentation must support the significant and separate E/M claim.

Here's what the changes mean to you.

Lump All Inpatient Consults as 99251-99255

This winter you won't have to question whether an inpatient consultation is an initial or follow-up consult--a distinction that otolaryngology coders have long struggled to comprehend. -Physicians never used the follow-up consultation codes correctly,- says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

New method: You-ll bill all inpatient consults as 99251-99255 (Initial inpatient consultation for a new or established patient -). Report follow-up inpatient care with subsequent hospital care codes 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient -).

Replace Follow-up Consult With Subsequent Care Code
 
When an otolaryngologist receives a proper request for a consult in the inpatient setting, you may claim one initial inpatient consult (99251-99255) per hospital admission. These codes won't change for 2006. However, if the otolaryngologist sees the same patient during the same inpatient stay, you should report subsequent hospital care codes, not follow-up inpatient consult codes (99261-99263, which CPT 2006 will eliminate).

Example: After an otolaryngologist renders his opinion on a heart attack patient's sinusitis, the ENT continues to check on the patient during his hospital stay. -Because the ENT is managing the patient's subsequent sinusitis care, you should code the subsequent visits with 99231-99233,- Callaway says.

Current way: Suppose instead of managing the patient's sinusitis, the otolaryngologist only initially evaluates the inpatient and prescribes an antibiotic for him. Four days later, the cardiologist contacts the otolaryngologist and reports that the antibiotic is not working. Based on the cardiologist's request, the otolaryngologist sees the patient again to change the plan of care. You would currently report the second encounter as a follow-up inpatient consult (99261-99263). Next year, CPT will eliminate this option, so you will have to charge subsequent hospital care (99231-99233).

Consider 99251-99255 per Hospital Admission

A new hospitalization opens the door to another potential initial inpatient consult. When a physician discharges a patient--even if the physician readmits the patient a day later--you may bill an initial inpatient consult, if the encounter meets a consultation's criteria.

Use Right Diagnoses to Capture Dual E/Ms

Pay attention to diagnostic coding to help you avoid denials for two same-day, different-specialist E/M services.

In the above initial-subsequent-care scenario involving the sinusitis/heart attack patient, each specialist in 2006 should report subsequent hospital care (99231-99233). Therefore, the insurer will receive two subsequent hospital care claims for the same patient on the same date of service.

Key: Each specialist must report the condition(s) he cares for to ensure that the dual charge doesn't trigger a denial. -ICD-9 instructs the physician to list all of the diagnoses he or she addressed during that exam,- Callaway says. For the sinusitis/heart attack patient, the otolaryngologist would report sinusitis (such as 473.9, Unspecified sinusitis [chronic]), and the cardiologist would code the myocardial infarction (for instance 410.01, Acute myocardial infarction; of anterolateral wall; initial episode of care).

Gain Over $10 per Visit

Not only will CPT 2006 ease your inpatient coding, but 99261-99263's deletion will benefit your bottom line. -Level for level, subsequent care codes pay at a higher rate than follow-up consultation codes,- Callaway says.

Payment comparison: Codes 99231 and 99233 pay $11.75 more than 99261 and 99263, based on the 2005 National Physician Fee Schedule Relative Value File. Code 99232 reimburses $10.23 more than 99262.

Check Site, 3 R's for 99271-99275 Replacement

The new year will further whittle away your consultation code choices. CPT 2006 will also delete confirmatory consultation codes 99271-99275.

The replacement code for 99271-99275, however, isn't clear-cut. A confirmatory consultation could qualify as an office visit, an outpatient consultation or an inpatient consult, says Andrew Borden, CCS-P, CPC, CMA, reimbursement manager in the department of otolaryngology and communication sciences at Medical College of Wisconsin in Milwaukee.

To determine the appropriate code, look at the encounter's site of service and its consultation qualifications. If the visit meets a consultation's three requirements--request of opinion, rendering of services, and report to the requester--you should report a consult code.

Expect Source to Cost You Some Consults

-A confirmatory consult may not automatically be a consult,- Borden says. A source that meets a confirmatory consultation's criteria may not count as an appropriate source for an outpatient (99241-99245, Office consultation for a new or established patient -) or inpatient consultation (99251-99255).

Although CPT permits a patient, a family member, an employer or an insurer to request a confirmatory consult, insurers may stipulate that a physician has to request a consult. -Coders are going to enter a sticky business of deciphering whom an insurer considers an appropriate source,- Borden says.

Just because CPT eliminates confirmatory consults doesn't mean insurers will change their source requirements. -Physicians could lose some money because they have to report a new patient office visit (99201-99202, Office or other outpatient visit for the evaluation and management of a new patient -) instead of a confirmatory consult due to lack of an appropriate source,- Borden says.

Reserve 25 for Documented Cases

You probably know that you should claim a modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) visit only when the otolaryngologist's documentation supports a significant and separate service. CPT 2006, however, will reinforce this guideline.

The update will clarify modifier 25's explanatory text. The new explanation will state that a -significant, separately identifiable E/M service- should have documentation that meets the requirements for the E/M service being reported. This means that modifier 25 claims do not contain any new documentation criteria. CPT is just clarifying that the documentation must show that the E/M service is significant and separate from the same-day procedure or other service.

This revelation comes as no surprise to coders. -This change won't affect our physicians at all,- says Christine Letsen, CPC, billing coordinator at Metropolitan ENT, with four otolaryngologists in Alexandria, Va. They already know documentation must support the E/M components of history, examination and medical decision-making as a standalone service from the procedure that the physician billed.

Note: All code changes for CPT 2006 are tentative and depend on approval by the AMA conference in November.