Otolaryngology Coding Alert

Discover which code you’ll use for straightforward MDM in lieu of 99241.

Last month, Otolaryngology Coding Alert introduced you to the revised emergency department (ED) and observation evaluation and management (E/M) codes and guidelines in the AMA’s 2023 CPT^® code set. In this issue, you’ll learn about office and outpatient consultation coding updates that will take effect on Jan. 1.

If your practice includes inpatient and outpatient consultations, make sure you note these headline, guideline, code, and descriptor adjustments that align with the 2021 E/M rule changes to office/outpatient services so you can start coding in 2023 without missing a beat.

Preview What’s New in the Consultations Guidelines

In the 2023 updates, CPT^® has changed the wording in the consultations guidelines to allow “other qualified healthcare professionals” (QHPs) — such as a nurse practitioner (NP) or physician assistant (PA) — to perform E/M consultations in addition to starting diagnostic or therapeutic services during the visit or at a subsequent visit.

Moving on to the office/outpatient consultations guidelines, you’ll find CPT^® has revised the places of service (POS) in the following way:

• CPT^® 2022: “… report consultations provided in the office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, or emergency department.”
• CPT^® 2023: “… report consultations that are provided in the office or other outpatient site, including the home or residence, or emergency department.”

Mandatory modifier: The guidelines also state that you should append modifier 32 (Mandated services) to a consultation that is required. For example, if a payer requests a consultation, such as a second opinion before the payer approves treatment, you should append modifier 32 to the applicable consultation code.

Analyze Office Consultation Code Revisions

The updated consultation codes will allow providers to select the level of service based on medical decision making (MDM) or time. Here’s a sneak peek at the office/ outpatient consultation E/M codes for 2023 with portions of the revised descriptors emphasized for easy reference:

• 99242 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.)
• 99243 (… low level of medical decision making … 30 minutes must be met or exceeded.)
• 99244 (… moderate level of medical decision making … 40 minutes must be met or exceeded.)
• 99245 (… high level of medical decision making … 55 minutes must be met or exceeded.)

Notably, references to the level of history and examination are deleted and substituted with “a medically appropriate history and/or exam,” which mirrors the changes made in 2021 to the descriptors for the office/outpatient visit codes. Unlike the codes for office/ outpatient services, CPT^® does not specify a range of time for these consultation codes. Instead, the descriptors include a single time that must be “met or exceeded.”

Prolonged service code: CPT^® adds a parenthetical note after 99245, instructing you to use add-on code +99417 (Prolonged office or other outpatient evaluation and management service(s)…) for services lasting 70 minutes or longer.

If you’re billing an E/M visit solely on the basis of time, you can assign +99417 only after 15 minutes have elapsed beyond the minimum time required for the highest-level primary service. In cases of office/outpatient consultations, you cannot assign +99417 until 15 minutes have passed after the initial 55 minutes of the 99245 consultation — in other words, 70 minutes total. Don’t forget to check your individual payer policies, as not all payers accept consult codes, and those who do may have different rules and requirements regarding coding and counting time for prolonged services.

Descriptor modification: When the calendar flips to Jan. 1, 2023, the descriptor for code +99417 will change. The new descriptor removes the language telling you the code can only be used in conjunction with 99205/99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …); instead, you will use +99417 with any of the highest-level E/M services that can be billed by total time if your payer accepts prolonged service billing using CPT^® guidelines.

Key code deletions: In keeping with the level one office/outpatient E/M code deletions of 2021, CPT^® has deleted the lowest level office (99241) and inpatient (99251) consultation codes to align with four levels of MDM in 2023. Beginning Jan. 1, you’ll report 99242 for a consultation that involves straightforward MDM.

Consider MDM and Time When Coding Consultations in 2023

What do practices need to know before billing outpatient consultations next year? We asked industry experts, and this is what they had to say. “As part of the 2023 revisions, this range of consultation codes can be documented through either time or MDM. History and exam, as with office visits, are no longer key components of consultations,” says Nancy Clark, CPC, COC, CPB, CPMA, CPC-I, COPC, AAPC Fellow, senior manager at Eisner Advisory Group LLC in Iselin, New Jersey.

You should review your individual payer preferences, but as long as they don’t have specific additional requirements, come January, you and your providers can decide how to support your E/M consultation code choice — documented physician/QHP time on the date of service or MDM — for each encounter.

“There is nothing in CPT^® that indicates that you have to use only one or the other when calculating the E/M level. Each E/M level can stand on its own based on the documentation and what the provider decides the E/M level is predicated on — documented time or MDM,” adds Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.

What if you have a report that states the provider used a certain level of MDM, but the total time surpassed what’s assigned to the code for that level of MDM? “If the provider documents cumulative time along with the MDM and relevant history/ physical examination, the coder can select the method that benefits the provider,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Keep in mind: The provider has the ultimate responsibility to document and select the code. “If the provider believes the encounter was especially lengthy, they may choose to document the time spent in various activities and select a code based on time,” Clark adds.

Example: The otolaryngologist performs an E/M service in which the documentation supports moderate complexity (99244), but the total time for the consultation is 55 minutes (99245). In this case, you can report 99245 for the service providing your documentation can account for the total time spent performing face-to-face and non-face-to-face activities on the date of the encounter.

Documentation in the medical record should indicate how the physician time was spent — reviewing records, obtaining a detailed history, performing an exam, education and discussion with patient and family, discussing patient status with another provider on the care team. A cryptic note (e.g., patient was in the office x 55 minutes) would likely be challenged in a payer audit.

Coding tip: “What I have found while auditing the 2021 guidelines, which currently only apply to office/outpatient services, is that the documentation often can support a higher-level service using a new or established patient visit than can be supported using the 95/97 guidelines, which apply to consultation codes,” says Cobuzzi. CPT^® 2023 “eliminates this shift between the 2021 guidelines and the 95/97 guidelines since we will no longer be using the 95/97 guidelines as of Jan. 1, and instead will be using the 2023 modifications to the 2021 guidelines.”

For the full list of 2023 E/M code and guideline revisions, go to www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf.