Otolaryngology Coding Alert

Get providers on both sides of the aisle their deserved reimbursement.

Evaluation and management (E/M) services outside of your typical office/outpatient visit offer an added degree of difficulty due to the lack of frequency in which you’ll code them. That’s why you might find yourself needing to review the guidelines when your provider performs an intermittent interprofessional telephone/ internet/electronic health record physician-to-physician consultation, relays Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook.

When coding for these services, you must take numerous details and components of the exchange into account to reach the correct level of service. What’s more, coders for

physicians on both ends of this exchange need to know what details to look out for to get the coding mechanics down pat.

Utilize all the necessary guidelines — and a helpful example — to code these special consultation services accurately and confidently.

Report These Consultation Codes Under Appropriate Circumstances

In some instances, a treating otolaryngologist may reach out to a more specialized provider within the same specialty, or a provider of a different specialty, to discuss diagnostic and/or treatment management of a patient’s condition. So long as a strict set of criteria are met, both providers can bill for these services in some capacity using codes from the respective E/M subsection.

Scenario: For example, if an otolaryngologist consults with a requesting physician using audiovisual, telephone, or a virtual form of communication, the otolaryngologist may report one of the following consultation codes so long as a strict set of criteria is met:

• 99446 (Interprofessional telephone/Internet/ electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review)
• 99447 (… 11-20 minutes of medical consultative discussion and review)
• 99448 (… 21-30 minutes of medical consultative discussion and review)
• 99449 (… 31 minutes or more of medical consultative discussion and review)

This includes a variety of useful guidelines you should adhere to when coding for a consulting provider. For instance, the patient may either be new or established to the consulting provider, but the consulting provider may not bill for the service if they have seen the patient within the past 14 days. The use of code range 99446-99449 should also “conclude with a verbal opinion report and written report from the consultant to the treating/ requesting physician,” according to the CPT^® code book.

Factor in Time, Authoritative Guidance for Requesting Physician Coding

While the coding dynamics surrounding the consulting provider’s services are relatively straightforward, there isn’t as much guidance on how to proceed for the complete services involving the requesting physician. First, it’s important to understand that codes 99446-99449 are intended for billing by the consulting provider, not the requesting provider.

However, the requesting provider may still bill for services in requesting a consultation from another provider. CPT^® Assistant (October 2013; Volume 23: Issue 10) elaborates on this topic by explaining how a requesting provider should bill for services when the exchange between requesting and consulting physician extends beyond 30 minutes: “The treating/requesting physician or other qualified health care professional may report the Prolonged Service With Direct Patient Contact codes (99354-99357) for the time spent on the interprofessional telephone/ Internet discussion with the consultant (eg, specialist) if the time exceeds 30 minutes beyond the typical time of the appropriate evaluation and management (E/M) service performed and the patient is present (on-site) and accessible to the treating/requesting physician or other qualified health care professional. If the interprofessional telephone/Internet assessment and management service 

occurs when the patient is not present or on-site, and the discussion time exceeds 30 minutes beyond the typical time of the appropriate E/M service performed, then the Prolonged Service Without Direct Patient Contact codes (99358, 99359) may be reported by the treating/requesting physician or other qualified health care professional.”

This means that a requesting provider may include up to the first 30 minutes of dialogue between requesting and consulting provider into the typical time estimate for the underlying E/M service that resulted in the consultation request. However, you’ll want to know how to proceed when the provider’s typical time estimate extends beyond the time estimate for the highest-level E/M service, but the discussion between requesting and consulting provider does not exceed the 30-minute threshold.

Round Out Your Knowledge Using This Example

Example: A otolaryngologist performs an E/M visit for an established female patient with one-sided hearing loss. The otolaryngologist performs an in-office computed tomography (CT) scan in order to identify a mass. The visit lasts 40 minutes. Immediately following the visit, the otolaryngologist requests a consultation with a neurosurgeon to discuss surgical options for access and removal of the mass. The phone call lasts 20 minutes and the neurosurgeon spends another 10 minutes writing a review to be sent to the otolaryngologist.

In this instance, the consulting neurosurgeon will report code 99448 for 30 minutes of total time spent. To reach the correct E/M code for the otolaryngologist, you’ll want to total the amount of time spent during the office visit and the time spent conversing with the consulting physician. So long as you’re able to reach the 50 percent threshold for counseling and/or coordination of care services between the E/M visit and the consulting physician discussion, you’ve got enough to reach the highest established patient E/M level of service code 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).

You’ve still got 20 additional minutes you need to account for during the phone call. However, with respect to prolonged E/M services code +99354 (Prolonged evaluation and management or psychotherapy service(s) …), you may not report this code without reaching a total duration of 30 minutes or more of prolonged service time. Since the requesting physician did not reach 30 minutes of dialogue with the consulting physician, you may not report +99354 with 99215, as per CPT^® guidelines.

Note: Remember that the Centers for Medicare & Medicaid Services (CMS) will do away with the 50-percent threshold for time-based coding of office/ outpatient visits with the revised 2021 E/M guidelines.

Now, consider the same scenario as above, except the duration of the phone call between requesting and consulting provider lasts 30 minutes. Here, you’ll code for the consulting provider’s services totaling 40 minutes (including the 10-minute written review) using code 99449. Assuming the otolaryngologist is able to code using a typical time estimate, they will report code 99215. Next, since the provider has reached the 30-minute threshold of non-face-to-face prolonged services, the you may report code +99354 alongside 99215 alongside 99215.