Otolaryngology Coding Alert

If you believe that Medicare allows billing only one ED visit per day, you may be incorrectly reporting 99241-99245 for your otolaryngologist's services instead of 99281-99285.

When an ED physician requests your otolaryngologist's services in the ED, you may assume that you should report a consultation (99241-99245, Office consultation for a new or established patient ) rather than an ED visit (99281-99285, Emergency department visit for the E/M of a patient ). Many ENT coders think only emergency department (ED) physicians may use ED service codes. "ED codes are not limited to the doctors employed by the ED," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "To use 99281-99285, the physician must perform the service in the ED." The type of doctor does not matter.

In fact, even if an ED physician who requests another doctor's services assigns 99281-99285, the Medicare Carriers Manual (MCM) section 15507 instructs primary-care physicians and specialists also to report an ED visit, unless the doctor:

 

meets the criteria for a consultation
 

delivers critical care services (99291-99292, Critical care, E/M of the critically ill or critically injured patient ) upon arriving at the ED
 

admits the patient to the hospital (99221-99223, Initial hospital care, for the E/M of a patient ; 99218-99220, Initial observation care, per day, for the E/M of a patient ; 99234-99236, Observation or inpatient hospital care, for the E/M of a patient including admission and discharge on the same date ...).

If the otolaryngologist provides any of these three services, you should report the respective E/M service code instead of the ED visit. Knowing whether your ENT admits the patient is obvious. Knowing whether the visit meets the first consultation requirement request for an opinion may prove more elusive.

To meet these criteria, the ED physician must request the otolaryngologist's opinion on a patient, rather than transfer the patient's total care to the specialist. Therefore, you must determine which service your otolaryngologist performs for the ED physician to determine whether to report 99241-99245 or 99281-99285.

The key factor in whether you should code the visit as a consultation or as an ED visit is the intent behind the ED physician's request to the otolaryngologist. "Is the ED physician asking for an opinion?" asks Jean Ryan-Niemackl, LPN, CPC, an application support specialist for QuadraMed in Fargo, N.D. "Or is the ED physician asking the otolaryngologist to take over care of the patient?"

The MCM section 15506 B disallows consultations when the ED physician transfers complete patient care to the specialist. "Payment [for an initial consultation] may be made regardless of treatment initiation unless a transfer of care occurs," MCM states. "A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance." Therefore, if the ED physician asks the otolaryngologist to assume care of the patient and the patient is not admitted to the hospital, you should report the ED codes (99281-99285).

For example, an ED doctor asks an otolaryngologist to see a patient who has severe epistaxis (784.7) and requests that the otolaryngologist assume responsibility for the patient's complete care. In this case, because the ED physician transfers care to the otolaryngologist, you should report an ED visit, such as 99282 ( usually, the presenting problem[s] are of low to moderate severity), rather than a consultation (for example, 99242, usually, the presenting problem[s] are of low severity; physicians typically spend 30 minutes face-to-face with the patient and/or family).

Similarly, if the otolaryngologist subsequently admits the patient to the hospital (99221-99223) or observation (99218-99220), you should report that service. For a same-day admit and discharge, use 99234-99236. In these instances, the specialist assumes care of the individual, so a consultation code (99241-99245) is inappropriate.

Reporting a consultation is also incorrect when the ENT sends her own patient to the hospital and the ED physician requests her opinion. For instance, an otolaryngologist recommends that a mother take her child who has severe post-tonsillectomy hemorrhaging (998.11, Hemorrhage complicating a procedure) to the local ED. The ED physician asks for the otolaryngologist's advice. If the specialist goes to the ED, evaluates the patient and offers recommendations to the ED physician, you should bill an ED visit for the otolaryngologist.
 
Watch out for situations in which the ED doctor requests the ENT's opinion but the specialist offers advice over the phone. In the above example, if the otolaryngologist does not go to the hospital to see the child, you should not bill for any charges.

The specialist has to come in to the ED, says Barbara E. Oviatt, CPC, CCS-P, coding supervisor at Martin Memorial Medical Group in Stuart, Fla. "You can't bill unless there is a face-to-face encounter."

Another variation that may occur is that the otolaryngologist for convenience meets the patient at the ED and does not require the ED physician's services. Suppose the ENT in the hemorrhaging scenario tells the mother that she will meet her at the ED. If the specialist evaluates the patient and sends her home, you should bill an ED visit (99281-99285) if the otolaryngologist registers the patient in the ED.
 
For patient's who are not registered in the ED, you should report 99211-99215 (Office or other outpatient visit for the E/M of an established patient). Because the site of services will not match, the insurer may reduce the office visit payment to reflect no overhead expense.

Private Payers Play by Their Own Rules

 Although Medicare says you should use an ED code not an outpatient E/M code when the otolaryngologist sees a patient in the ED, some private carriers do not follow Medicare guidelines and may balk at paying an ED code for both an otolaryngologist and the ED physician. "Numerous policies contain capitation plans that allow only ED doctors to report ED codes," Cobuzzi says. In those cases, you should use the appropriate outpatient E/M codes (99201-99215) instead of the ED codes when an otolaryngologist treats a patient in the ED but doesn't admit him to the hospital. "Capitated plans force specialists to code inappropriately," she says.