Otolaryngology Coding Alert

When you-re coding new patient office visits and consultations, you-re stuck between a rock and a hard place.

If you bill all new patient encounters as higher-paying consultations (99241-99245, Office consultation for a new or established patient -), you-re sending up a red flag for payers. But if you err too conservatively to lower-paying office visits (99201-99215, Office or other outpatient visit ...), you-ll sacrifice payment. Here are some clever ways to differentiate a consult from an office visit.

Ask, "Why is the physician sending us this patient?" If the physician requests your ENT's opinion regarding a patient's treatment and/or plan, the service is on its way to qualifying as a consultation. On the other hand, you should use an office visit code for a referral.

Example: A pediatrician sends a patient with chronic tonsillitis (474.00) to your ENT and requests his opinion on continuing conservative antibiotic treatment rather than surgical tonsillectomy. Because the pediatrician asks for your physician's opinion and expects a treatment strategy report, the encounter could qualify as a consultation (99241-99245) -- if the service meets the remaining consultation requirements.

But suppose the patient has 3+ tonsils that are interfering with breathing. The pediatrician sends the patient to your office expecting that an ENT will admit the patient to the hospital for an immediate tonsillectomy (such as 42825, Tonsillectomy, primary or secondary; younger than age 12). In this case, the originating physician is out of the care loop -- and you should code an office visit (99201-99215) for the initial ENT-patient meeting.

Your ENTs may comply with documenting an office consultation's reason and request in the patient's chart. But how do you get sending offices to comply with this possible audit item? "Have staff over for a cocktail hour, and show them the value of distinguishing a referral (transfer of care) from a consultation (a request for opinion)," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. The educational training will more than pay for itself.

Encourage attendees to always use the term "request" when asking for a physician opinion and reserve "referral" for a transfer of care. The term "referral" presumes that the accepting physician will assume total care, disqualifying the visit as a consultation, according to Medicare guidelines.

Alternatively, when an office sends you a patient without indicating the physician's intent, fax them a consultation confirmation form (for a sample template, see "Stop Trying to Read the Requesting Physician's Mind -- Use This Confirmation Sheet Instead" in Otolaryngology Coding Alert, January 2007). If the practice complains about the forms, explain that you will continue sending them until the practice makes the visit's encounter clear.

Timesaver: Some otolaryngology practices note that many offices now beat them to the punch. The sending office staff made a copy of the ENT's form that staff completes and sends with each patient.

If an auditor looks at your consultation charts, showing that you kept the originating physician in the loop helps support your coding, Cobuzzi says. Include a statement at the end of your report to the requesting physician, such as, "Unless I hear from you otherwise, I will continue with the above plan of care." Without a report, you-ve got an office visit.

Example: An emergency department (ED) physician treats a patient for epistaxis and sends the patient to you for follow-up. "This is not really a consult because the [ENT] would not be reporting back to the ED physician," says Rhonda Buckholtz, CPC, director of local chapters for the American Academy of Professional Coders and a PMCC-approved instructor.

Think of consultations as patients whom you borrow like Netflix movies, Cobuzzi says. "Whether you keep the movie for a day or for six months, you eventually have to send the DVD back to the issuing company." Similarly, a patient must eventually go back to the requesting physician.

Example: An internist's patient comes in for a consult due to a neck mass biopsy confirming a cancer diagnosis (195.0, Malignant neoplasm of other and ill-defined sites; head, face and neck). The internist asks for the otolaryngologist's opinion on surgical and radiological options.

Because the ENT spends the majority of the face-to-face encounter on counseling, he codes the surgical consult based on time with 99243 (- physicians typically spend 40 minutes face-to-face with the patient and/or family). The office manager sends a copy of the ENT's report back to the internist.

The patient decides to undergo surgery with the ENT. After a preoperative E/M, radical neck dissection (31365, Laryngectomy; total, with radical neck dissection), postoperative E/Ms, and additional visits spanning six months, the ENT discharges the patient. The otolaryngologist issues a letter to the internist indicating that the patient is cancer-free and, barring any recurrences, the surgeon would like to see the patient in a year.

Key: The discharge order officially returns the patient to the requesting physician, completing the care circle.