Otolaryngology Coding Alert

Counseling, established patients get you an encounter faster 

If you code an office visit only when your otolaryngologist documents a history, examination and medical decision-making, you're missing reimbursement for deserved services.

You can throw the "all of the key components" rule out the window in two instances: established patient office visits and counseling-dominated encounters. To improve your reimbursement, experts reveal the essentials of E/M service coding:

New Patient Office Visits, Consults Require HEM

To bill 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient) or 99241-99245 (Outpatient consultations), your otolaryngologist must base the visit's level on all three components. That means he or she must take a history, perform an examination and provide medical decision-making, says Rebecca McKinney, CPC, financial analyst at WakeMed Faculty Physicians ENT -- Head and Neck Surgery in Raleigh, N.C.

Tip: Select the appropriate new patient office visit level or consultation level based on the lowest E/M component. "The history, exam and medical decision-making need to be at the same level or higher to support the level of care," says Teresa M. Thompson, CPC, CCC, an ENT coding specialist and the owner of TM Consulting, a national medical consulting and management firm in Sequim, Wash.

Example: A family physician requests an otolaryngologist's opinion regarding a 55-year-old male patient who has progressive hearing loss. The specialist takes a detailed history, performs an expanded problem-focused examination and uses straightforward decision-making. For the outpatient consultation, you should report 99242 (Office consultation for a new or established patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision making) based on the lowest component(s): the exam and decision-making, which are at the same level. You lose the extra history.

Codes 99212-99215 Need 2 out of 3

Supporting a higher-level service is easier with established patient office visit codes (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...). "You need only two components to substantiate 99212-99215," McKinney says.

Watch out: You may accidentally downcode if you select the established patient office visit code based on three out of three components. "Many ENTs don't know 99214 requires only two of the three components," says Thompson, who presented "E/M Chart Audit for the ENT Practice" at the Association of Otolaryngology Administrators conference in Orlando, Fla.

Right way: Look for the two highest or same-level components. For instance, an allergic rhinitis patient presents for a follow-up exam and also complains of ear pain. The ENT's nurse takes a detailed history. The otolaryngologist reviews her notes and performs a problem-focused exam with low-complexity medical decision-making. Based on the two highest components, the history and medical decision-making, you should report 99213 (... which requires at least two of three key components: an expanded problem-focused history, an expanded problem-focused examination, medical decision making of low complexity).

Pitfall: If you coded the above encounter using the three-out-of-three-components rule, you'd report 99212 (... a problem-focused history, problem-focused examination, straightforward decision making) based on the lowest component, an error that would cut about $15 from the claim.

Time Governs Counseling-Dominated Visits 
 
When counseling is the controlling factor, you don't need any components in determining the visit's level. You simply select the appropriate E/M code based on the time the otolaryngologist spent providing the encounter, Thompson says.

You can use time as the key factor as long as counseling and/or coordination of care dominate the encounter. So, your otolaryngologist must spend more than 50 percent of the visit counseling the patient.

Be careful: Documentation must clearly show that counseling and/or coordination of care dominated the encounter. Billing by time often drives the E/M level up much higher, McKinney says. So, payers may challenge the selected code or even downcode the visit based on medical necessity.

Solution: Make sure the notes show how much total time the otolaryngologist spent with the patient, how much time he spent counseling the patient or coordinating the patient's care, and what he discussed. A short abbreviation, T/C (total time/counseling and/or care coordination time), followed by the counseling and/or care topic, can easily document this crucial information.

For instance, in McKinney's practice, which treats many cancer patients, the otolaryngologist might note: "45T/30C, discussed handling chemotherapy side effects." The notation indicates that the otolaryngologist spent a total (T) of 45 minutes on the visit with 30 counseling (C) minutes addressing the patient's treatment symptoms.

Since counseling dominates the encounter, you should report 99215 (... a comprehensive history, a comprehensive examination, medical decision making of high complexity) for the visit's total 45 minutes. Even if the history, examination and medical decision-making support only a level-three visit (99213), the documentation will clearly support billing the higher-level E/M.