Otolaryngology Coding Alert

You'll need 3 of 3 key components to choose a service level for new patients

If you-re coding your ENT's visits with rest home patients using nursing home care codes, you-re setting yourself up for a problem. Rest homes are a distinct place of service and require that you report a specific set of E/M service codes.

For 2006, CPT has revised its guidelines for services the physician provides to domiciliary, rest home or custodial care patients. You should find the revisions to your liking because the new guidelines closely mimic those you regularly apply for office or other outpatient visits.

Watch Your Place of Service

A rest home, domiciliary or custodial care facility (place-of-service code 33)--as defined by both CPT and CMS---provides room, board and other personal assistance services, generally on a long-term basis.- Such facilities do not have a medical component, which distinguishes them from a nursing facility (place-of-service code 32), says Marvel J. Hammer, RN, CPC, CCS-P, CHCO, president of MJH Consulting in Denver.

Rest home isn't a private residence: You should use home service codes 99341-99350 only when the physician provides E/M services to a patient in his -own private residence and not any type of facility,- according to CMS rules. This means that even if the patient is truly -at home- in the domiciliary or rest home, you would not use 99341-99350, says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at a multi-physician practice in New Brunswick, N.J.

Out With the Old, In With the New

After Jan. 1, you should use one of nine new codes to describe services that the physician provides in rest homes:

- 99324-99328 (Domiciliary or rest home visit for the evaluation and management of a new patient .. levels one-five)

- 99334-99337 (Domiciliary or rest home visit for the evaluation and management of an established patient ... levels one-four).

CPT designed the new codes -to better capture the level of care provided in these settings consistent with increase of patients with complex disease who are eligible for this type of care- [and] remain in non-medical facilities,- according to the AMA's CPT Changes 2006: An Insider's View.

CPT makes it easy: -The new codes are based on the three key components: history, exam and medical decision-making,- says Kathy Pride, CPC, CCS-P, a consultant with QuadraMed in Port St. Lucie, Fla. This means you-ll choose from among 99324-99337 almost exactly as you would choose among office outpatient visits 99201-99215.

For instance: To report the lowest-level new patient visit in a rest home, your physician will need to document a problem-focused history, problem-focused examination and straightforward medical decision-making (MDM)--exactly the same requirements for a level-one E/M service for a new patient visit in the office (99201, Office or other outpatient visit for the evaluation and management of a new patient). 
 
As with the new patient office/outpatient visits, you must meet all three requirements to report a given level of service with new patient custodial care codes 99324-99328.

Example: Your otolaryngologist visits a new patient in a domiciliary for an evaluation. The physician documents a comprehensive history and exam, and MDM that qualifies as -low complexity.-

In this case, you must choose 99325. Although the comprehensive history and exam point to 99327, this code requires MDM of moderate complexity. Because all three components must meet or exceed the requirements of the chosen service level, 99325--not 99327--is correct.

2 of 3 Meets the Need for Established Patients
 
For an established patient, you need only meet or exceed two of the three requirements to report a particular level of service. Once again, this mirrors the long-standing guidelines that apply to established patient office/outpatient visits, Hammer says.

Example: The otolaryngologist returns at a later date to evaluate the patient in the above example for a new complaint. The service consists of a problem-focused history, a detailed exam and MDM of moderate complexity. In this case, you can select 99336--even though a problem-focused history does not meet the requirements of that service--because the physician has documented the remaining two requirements (a detailed exam and MDM of moderate complexity).