Otolaryngology Coding Alert

Vertigo, or dizziness, can have many potential diagnoses, but otolaryngologists should not bill new office visits or consults with vertigo patients at a predetermined evaluation and management (E/M) level or assume that such visits automatically reach a level four or five. Levels of such visits can vary dramatically depending on the differential diagnosis and the treatment options, tests (both ordered and reviewed) and risk that flow from it.

Although the otolaryngologist may perform a comprehensive history and physical (H&P) when seeing a new vertigo patient (i.e., qualifying for a level-five E/M service), the visit as a whole may not exceed a level two or three because the medical decision-making (MDM) does not support a higher claim. On the other hand, the MDM may reach high complexity, which, in conjunction with a comprehensive H&P and proper documentation, allows a level-five visit to be paid.

The level of MDM for vertigo is determined principally by the differential diagnosis, which can vary significantly from case to case. Dorlands Medical Dictionary defines differential diagnosis as the determination of which one of two or more diseases or conditions a patient is suffering from, by systematically comparing and contrasting their clinical findings.

When the physician first sees a vertigo patient, the differential diagnosis may include dozens of potential diseases or conditions, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPTs editorial panel and executive committee. Differential diagnoses will differ based on the history the otolaryngologist documents. When I take a history, Im already developing possible diagnoses for the problem. As I learn more about the patients history, the number of differential diagnoses narrows, Eisenberg explains.

While attempting to pinpoint the diagnosis, the number of questions the otolaryngologist asks the patient almost invariably raises the history to a comprehensive (highest) level. By the time the otolaryngologist examines the patient, he or she may already suspect a possible diagnosis. And because vertigo patients typically present with few if any physical symptoms, the exam although extremely thorough and therefore qualifying as a comprehensive single-system ENT exam will likely be normal and confirm the otolaryngologists hypothesis of the cause of the condition or disease.

Determine the Level of MDM

For outpatients (including new patients), there are four MDM levels straightforward, low complexity, moderate complexity and high complexity corresponding to a particular level E/M code. Level-one and -two E/M codes, for example, require straightforward medical decision-making. Level-three codes require low complexity, while level-four codes require moderate complexity, and level-five codes require high complexity.

Note: Inpatient E/M codes have only three categories: low, moderate and high.

To calculate the correct level of MDM, three factors must be considered:

Number of diagnoses or management options;
Tests and records reviewed or ordered; and
Amount of risk.

Each of these factors is further categorized. The number of diagnoses, other problems and management options can be minor (one problem or option), low (two problems or options), moderate (three problems or options, or one new problem) or high (four or more problems or options, or one new problem with workup). Similarly, the amount of data reviewed, ordered or to be ordered is either minimal (zero to one test or record), limited (two), moderate (three) or extensive (four or more). The third component involves evaluating the risk to the patient, which is again graded as either minimal, low, moderate or high.

Note: Time is not a factor when determining the complexity of MDM.

Because the patients diagnosis and the otolaryngologists treatment plan are crucial to determining MDM, new patient or consultation MDM levels for vertigo patients can vary from straightforward to high complexity, Eisenberg says.

If the patients vertigo results from a central origin, such as a brain tumor, an acoustic neuroma or multiple sclerosis (MS), the MDM will be higher than if the vertigo originates in the middle ear, Eisenburg says. Furthermore, he explains, the MDM for inner ear conditions can also vary dramatically, as illustrated in the following vignettes:

1. A 23-year-old male patient with dizziness and hearing loss is diagnosed with acute labyrinthitis (inflammation of the labyrinth, 386.3x). The MDM for this patient is not particularly complicated, Eisenberg says, noting that the number of tests reviewed or ordered is relatively small. In addition, the risk to the patient who is expected to return to normal within a month is not great, and the condition does not require a large number of treatment options. Therefore, Eisenberg says, the MDM level is unlikely to exceed low complexity (which qualifies for a level-three new-patient visit or consultation).

2. A 47-year-old female has been unsteady for six months (slightly worse over time), has experienced dizziness in a hot tub and has had one brief episode of slurred speech. MS, a life-threatening disease, is suspected. Although the otolaryngologist may not specifically note the MS diagnosis (to avoid labeling the patient until the diagnosis is confirmed), the number of tests ordered and the patients treatment plan, as well as the abrupt change in the patients neurologic status which contributes to the level of risk indicate that the MDM was of high complexity.

3. A 27-year-old male reports dizziness, as well as ear pressure, ringing and roaring sounds in his ears, nausea, vomiting and stuffiness. Until recently, the symptoms lasted for a few hours, then abated. During the last episode, however, full hearing was not restored. The examination is completely normal, but a hearing test shows low-frequency hearing loss. Mnires disease (386.0x), which could lead to loss of hearing, is suspected. The otolaryngologist orders allergy and syphilis tests and places the patient on a low-salt diet with diuretics.

Because this patient faces potential hearing loss, the MDM is more complex than for a patient with labyrinthitis, who will be better in a few weeks, Eisenberg says. The patients treatment plan is more extensive, more tests are ordered, and the risk to the patient [loss of hearing] is significantly greater. Therefore, he says, decision-making of at least moderate complexity has likely been performed.

How to Document MDM

Although MDM of moderate complexity may have been performed in the course of diagnosing the new vertigo patient with Mnires disease, inadequate documentation can force what should have been a 99204 to a 99202 (or even a 99201, if the documentation is non-existent). Carriers determine levels of E/M service (including MDM) based solely on the documentation provided by physicians (unless time becomes the key factor during the visit). Even if the otolaryngologist who documents inadequately is reimbursed for a high-level visit, the money (plus fines, etc.) may have to be returned in the event of an audit.

Correctly documenting MDM is not complicated, however. All that is necessary is a record of what was ordered and reviewed, with the patients problems described in writing. Viewed this way, the requirement shouldnt demand much additional effort by otolaryngologists, who gather all this information routinely anyway, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

Neither HCFA nor private carriers dictate the form or style of the documentation. Otolaryngologists can customize a form that conforms to their own way of practicing, or they can dictate, perhaps using a form as a guide to make sure they dont miss anything.

Determining the level of decision-making has always been the hardest job for coders who arent clinically trained, Callaway says. But if the documentation is on the record, at least the coder has some tools to aid him or her in calculating the types of decisions the physician had to make. Doctors typically have to talk about the treatment plan or recommendations, and on that basis coders can gauge level of complexity of decision-making.

Of course, she adds, the best way to discern the MDM level for a particular visit is to have otolaryngologists determine it for themselves.