Otolaryngology Coding Alert

Experts reveal 99241-99255's who, what and where requirements

You can get the added revenue a consultation generates without raising a red flag, as long as your ENT's documentation shows that a proper source requested his opinion and he notes that he's sending a report of his findings to the requesting party.

With consultations making the Office of the Inspector General's 2004 Work Plan, inappropriately coding consultation services could mean you'll risk federal audits and requests for paybacks. To improve your reimbursement without triggering the OIG's scrutiny, coding experts answer these three questions on reporting consultations.

1. Who Qualifies as a Requesting Source?
 
For private payers, you may report a consultation when an independent speech therapist or a school nurse requests your otolaryngologist's opinion. Medicare, however, does not consider these individuals valid sources, says Betsy Nicoletti, CPC, a consultant with Helms & Company, a physician practice management company in Concord, N.H. Medicare specifically states that only a physician, a nurse practitioner, a physician assistant or a certified nurse midwife may request a consultation, she says.
 
CPT, on the other hand, also allows "another appropriate source," such as physical therapists, occupational therapists, speech therapists, psychologists, social workers and even lawyers to request an opinion. You may assume that third-party payers will use CPT rules unless they inform you otherwise, Nicoletti says.
 
For instance, suppose a school nurse notices that a child frequently slurs his speech. She notes her concerns and requests an otolaryngologist's opinion on the boy's speech impediment. Because the child has private insurance coverage, you may code a consultation (99241-99245, Office consultation for a new or established patient ...) for the otolaryngologist's services if she documents the nurse's request and issues a report of her findings to the school nurse.

2. What Consult Criteria Does Medicare Require?

For a service to qualify as a consultation, the visit must fulfill the three R's - request, review and report, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions in Lakewood, N.J. In a nutshell, documentation must show that there is a request for an opinion, a rendered opinion, and a report sent back to the requesting physician, according to the Medicare Carriers Manual.

Make sure that a payer-recognized source requests your otolaryngologist's opinion. If no valid request exists, you should report a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) as long as your practice hasn't seen the patient in the last three years, Cobuzzi says. For patients your otolaryngologist has seen during that time, use an established patient office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...).

In addition, you should verify that the primary-care physician (PCP) records the request for opinion in his patient's file. To encourage the PCP to put this documentation in his patient's charts, fax a request for opinion confirmation to the requesting physician, Cobuzzi says.

3. Where Should I Look for the Documentation?

Your otolaryngologist must document the consultation request somewhere in the medical record. For hospital inpatients and group medical practice patients, your otolaryngologist may note the request in the patient's common medical record.

Suppose an internist notes in the physician order his request for an otolaryngologist's opinion on a hospital patient with parotiditis. The otolaryngologist evaluates the patient and performs a same-day complicated parotid drainage (42305, Drainage of abscess; parotid, complicated). The shared request documentation is sufficient to report an initial inpatient consultation (99251-99255-57, Initial inpatient consultation for a new or established patient ...; Decision for surgery), if the otolaryngologist also documents his findings.

In an office setting, a letter, form or note requesting the otolaryngologist's opinion will protect your practice if you are audited. If an attachment in the patient's medical record supports the consultation request, make sure you refer to the letter or form in the chart note, says Teresa Thompson, CPC, CCC, a national ENT coding speaker and president of TM Consulting in Carlsborg, Wash. "That way, an auditor can easily find the request's documentation."

If your office doesn't have forms for requesting physicians to use or the primary doctor doesn't issue written requests, encourage your otolaryngologist to document the request in the first sentence of his report, Nicoletti says. For instance, a family physician calls and asks your otolaryngologist to see a patient who has a long history of some stomach-acid reflux problems. To support an outpatient consultation (99241-99245), your otolaryngologist should note: I am seeing this patient at Dr. Jones' request for my opinion about her stomach problems.

After the patient evaluation, make sure your otolaryngologist documents that he reported his findings to the requesting physician. Once again in an inpatient setting or a group practice, you may consider your otolaryngologist's findings in the common medical record sufficient proof to code a consultation (such as 99251-99255, 99261-99263l, Follow-up inpatient consultation), as long as your physician documents the first two R's, Nicoletti says.

To support a consultation in an outpatient or non-group practice setting, documentation must show that your otolaryngologist sent a letter describing his or her findings to the requesting physician, Cobuzzi says. Keep a copy of this letter in the patient's chart. If your otolaryngologist doesn't reference the letter, indicate on that date-of-service's note where the requesting doctor's letter is.