Otolaryngology Coding Alert

How 1997 guidelines may increase level of history, examination key components

You could sacrifice level-four established patient office visits if you don't use the E/M guidelines that benefit your practice most.
 
Federal guidelines surpass CPT in defining specific E/M code requirements. Although your practice may choose whether to follow the 1995 or 1997 guidelines, you must stick with one system.
 
Pitfall: If you use the wrong guidelines, you could reduce the level of services you bill. To find out which guidelines are ENT-friendly, read on.
 
Note: The following recommendations assume that medical necessity supports the billed services and apply mainly to practices with adult clientele. Some otolaryngology practices, such as pediatric otolaryngologists, may prefer using the 1995 guidelines because they don't typically perform the 12 bullets mentioned. Pediatric ENTs don't typically treat patients with chronic conditions.

Opt for 1997

Your otolaryngologist will usually reach a higher-level E/M service with the 1997 guidelines. This version makes two of the three key components that comprise an established patient office visit (99211-99215, Office or other outpatient service for the evaluation and management of an established patient ...) more attainable when an otolaryngologist treats common chronic ENT-related problems, such as rhinitis and sinusitis.
 
Strategy: Generally, you should opt for the 1997 version. "The 1997 guidelines are better for specialists to use," says Kimberle R. Cook, RHIT, CPC, reimbursement analyst lead at MeritCare Health System in Fargo, N.D.
 
Some ENT coders, however, are simply handed a set of guidelines and told to use them. For instance, Julie Roberston, CPC, says her practice has always used the 1997 guidelines. "The university as a whole decided to use that system, because we are a teaching institution," says Robertson, an otolaryngology coding and reimbursement specialist at University ENT Specialists in Cincinnati.
 
Opportunity: One day you may need to know what system your practice should use and why. You may join a new practice that doesn't know which guidelines to use. Or during a financial audit, your otolaryngologists may want to know if their E/M system benefits them the most. Here's why the 1997 E/M guidelines may help your practice:

Conditions' Status Boosts HPI

First, you may ethically report a more extensive history key component if you use the 1997 guidelines. Unlike the 1995 version, "the 1997 history elements don't require the four elements of HPI for an extended level because you can use the status of three chronic conditions," Cook says.
 
Benefit: Your otolaryngologist doesn't have to go into as much detail to renew an annual prescription for you to code a higher-level E/M.
 
For instance, a Medicare patient who has chronic controlled asthma (such as 493.01, Extrinsic asthma with status asthmaticus), severe allergies (477.x, Allergic rhinitis) and irritated sinusitis (473.x, Chronic sinusitis) presents for his annual checkup. The otolaryngologist notes: