Otolaryngology Coding Alert

Remember, what used to be a consultation is now likely a 99201-99215 service.

Medicare's deletion of consultation codes means that coders will have to answer the new versus established patient question more often than before. Answering incorrectly could send auditors calling.

Nail the patient's status every time by following this expert advice on new and established patients.

Ask 3-Year Question First

If your patient has had a face-to-face service with the otolaryngologist (or another physician with the same specialty credentials in your group) within the last three years, then the patient is established, confirms Kami Culb, office coordinator at Frederick Memorial Hospital Immediate Care in Maryland.

Example: A patient reports to the otolaryngologist for an E/M service that included documentation of a detailed history, detailed exam, and low complexity medical decision making on June 20, 2010. The patient's record indicates that she received a face-to-face E/M service from the otolaryngologist on June 19, 2007. This is a new patient, even though she's seen the otolaryngologist before, so you should report 99203 (Office or other outpatient visit for the evaluation and management of a new patient ... a detailed history; a detailed examination; and medical decision-making of low complexity), which pays $97.79 using the Medicare 2010 Physician Fee Schedule national rate, instead of the level-four E/M code for an established patient 99214 (... a detailed history; a detailed examination; medical decision making of moderate complexity ...), which pays $98.51.

Face Time a Must for Established Patients

The rules change if the patient has visited the office in the last three years but the otolaryngologist did not lay eyes on the patient.

Do this: "Interpret the phrase 'new patient' to mean a patient who has not received ... an E/M service or other face-to-face service from the physician or physician group practice within the previous three years," recommends Shelby Davidson, CPC, CMSCS, coding educator at OHMFS in Ohio.

Example: A patient reports to the otolaryngologist for an E/M service on May 28, 2010. The patient's record indicates that the otolaryngology practice provided an H1N1 vaccination, administered by a medical assistant, on Sept. 1, 2009. There was no record of a face-to-face service with a physician. You should choose a new patient E/M code (99201-99205) for the May 28, 2010 service.

Check Specialty When Deciding Status

Coders that work in multispecialty practices will have to pay attention to one more new/established patient status rule, confirms Cathy Satkus, CPC, coder for a multispecialty practice in Tulsa, Okla.

Example: Your practice includes otolaryngologists, internists, and dermatologists. A patient reports to the otolaryngologist for an E/M service on March 15, 2010. The patient's medical record indicates that he received a basal cell carcinoma evaluation from the practice's dermatologist a year ago. You would code this as "a new patient (99201-99205), since the specialty is different," Satkus says.