Otolaryngology Coding Alert

Otolaryngologists typically get called to the emergency department (ED) for cases of severe epistaxis, nasal fractures and airway obstructions. Although such encounters routinely are billed as consultations by many otolaryngologists, this is inappropriate. National Medicare guidelines state that ED codes (99281-99285) should be used, unless services qualify as admission (inpatient or observation) or critical care.

In fact, there are at least seven different ways to bill an ED encounter, depending on the status of the patient:

1. ER visit
2. Consultation
3. Admission
4. Admit to observation
5. Critical care
6. Established patient visit
7. New patient visit

These choices make it difficult to correctly code ED services provided by the otolaryngologist. To bill appropriately, coders depend on the otolaryngologists documentation of the encounter. Instead, what they often get is a short note that says ED consult, or Met patient in ED without other documentation to support a consultation. To avoid claim denials, otolaryngologists need to provide a full explanation of procedures to their coders.

Consultations in the ED

Possibly the biggest area of confusion when otolaryngologists bill for ED services is consults. According to the Medicare Carriers Manual (MCM): If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are met.

The three criteria are stated in the MCM, section 15506:

1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a
specific problem is requested by [the ED]p physician.

2. A request for a consultation from [the ED physician]
and the need for consultation must be documented in the patients medical record.

3. After the consultation, the consulting physician
prepares a written report of findings that is provided to the [ED doctor].

In the hospital setting, a separate report is not required. The report can be an entry in the patients common medical records (i.e., progress notes, recommendations for treatment, etc.). Section 15506 states: In an emergency department or inpatient or outpatient setting in which the medical record is shared between the referring physician and consultant, the request for consult may be documented as part of a plan written in the requesting physicians progress note, an order in the medical record or a specific written request for the consultation. In these settings, the written report required for consult may consist of an appropriate entry in the common medical record.

If the consultation criteria listed above are not met and the patient either is discharged from the ED or admitted to the hospital by another physician, the otolaryngologist contacted by the ED physician should bill an ED visit, not a consult. If the consultation criteria arent met and the otolaryngologist admits the patient, an initial hospital care code should be billed.

Although many otolaryngologists believe that because they are on call, they are by definition performing a consult and routinely bill visits to the ED as such. This often is incorrect. This error particularly relates to Medicare, which states that consults should not be billed if a transfer of care was the initial intent. Due to the nature of the ED physicians job, transfers of care often occur. In those instances, a consult cannot be billed.

In addition, the service can be called a consult only if the ED physician asks the otolaryngologist for advice on how to treat the patient. And even then, if the ED physician already has done a workup on the patient, the otolaryngologist may not be able to bill for a consult.

In other words, says Randa Blackwell, a coding specialist with the department of otolaryngology at the University of Maryland in Baltimore, if the patient has severe epistaxis and the otolaryngologist takes over the management of the patient, its a transfer of care, and a consult should not be billed.

On the other hand, Blackwell adds, if the patient had a closed nasal fracture or a possible concussion, and the otolaryngologist is called in to evaluate the patient and make a recommendation, and the ED physician resumes care, a consult is appropriately billed.

If the ED physician asks for an opinion on what to do with the possible fracture because he is uncertain about whats wrong with the nose and requires the otolaryngologists expertise, that would be a consult, Blackwell says. If the ED physician takes an x-ray, however, and determines the patient has a broken nose and calls the otolaryngologist and says, I want you to fix his nose, thats an ED visit.

A consult also may not be charged if the otolaryngologist sends his or her own patient to the ED, and later is asked for advice by the ED physician. If, based on the opinion of the otolaryngologist, the patient is sent home, both the ED physician and the patients otolaryngologist should bill the appropriate level of ED service, according to the MCM. The otolaryngologist does not bill for a consultation because he or she is not providing information to the ED physician for use in treating the patient, even though the ED physician asked for the otolaryngologists opinion.

Note: If the patients personal physician does not come to the hospital to see the patient, but only advises the ED physician by telephone, then the patients personal physician may not bill anything at all.

Second Physician Also Can Bill ED Services

The MCM guidelines in section 15507 now state:

These codes [99281-99285] should be paid
regardless of whether the physician is assigned to the emergency department.

Any physician seeing a patient registered in the
emergency department may use these codes.

ED codes should only be used if the patient is seen
in the emergency department.

ED codes should be paid regardless of whether the
services were emergency services, as long as the
patient was seen in the ED. A lower level ED code
should be reported for a non-emergency condition.

The problem has been how to bill if a patient came to the ED, saw a specialist and wasnt admitted to the hospital, says Kathy Pride, CPC, CCS-P, a coding and reimbursement specialist at Martin Memorial Hospital in Port St. Lucie, Fla. We never had a clear directive from our local carrier, so we relied mostly on word of mouth, basically, about how to do it. Some consultants said it was OK to charge for a consult. Then, when consults came under scrutiny, we were told to use office or other outpatient codes (99201-99215), with the ED as the place of service.

Conditions for Billing E/M

Under the current guidelines, otolaryngologists who see patients in the ED can bill for any evaluation and management (E/M) services performed there using emergency department E/M codes, unless:

1. The patient is admitted to the hospital or to
observation on the same calendar date, in which case
initial hospital care or admit to observation codes
should be used;

2. The encounter meets the criteria for a consult or for
critical care services; or

3. The patient is not registered at the ED, even though
he or she met the otolaryngologist there; in such
cases, an outpatient visit code (99201-99215) should
be reported, with 23 (ED) listed as the place of service.

Note: This likely will be subject to a site of service differential, whereby the carrier lowers the fee to reflect the fact that the physicians office costs arent taken into account because the service was provided elsewhere.

In the past, many private payers and local Medicare carriers only accepted one ED claim per patient per day. So if an ED physician saw a patient and then asked an otolaryngologist to take over care of the patient, the otolaryngologist had two options: If the patient was admitted, an initial hospital visit code was billed; if the patient remained in the ED, the otolaryngologist would bill the encounter as a new or established patient outpatient visit.

A new or established patient outpatient code also may still be required by some payers, including some local Medicare carriers, that still look askance at concurrent emergency department billing by an ED physician and an otolaryngologist or other specialist. Billing such carriers with an ED code often will result in the otolaryngologists claim being denied. Although appealing such denials may be successful, doing so again and again can be time-consuming. So coding experts recommend getting the carriers policy on MCM section 15507 (preferably in writing) before billing ED codes.

If the carrier will not recognize two ED codes on the same day for the same patient, an outpatient code should be used with the ED listed as the place of service on the HCFA 1500 claim form.

Note: If local Medicare carriers deny the otolaryngologists ED claim, the Medicare Carriers Manual, section 15507 should accompany any appeal. If these denials become routine, a form letter outlining the regulations in section 15507 should be developed to be used in these situations.

Choosing the Right Admit or Observation Code

If the otolaryngologist sees the patient in the ED and then admits the patient to the hospital on the same calendar date, only the admission (99221-99223) can be billed, according to the MCM. All E/M services provided by the otolaryngologist are considered part of the initial hospital care when performed on the same date as the admission.

For example, an otolaryngologist is called in to see a patient that is hemorrhaging as a result of a post-tonsillectomy bleed. After performing an evaluation and determining that the patient should be brought to the operating room, the otolaryngologist admits the patient and controls the hemorrhage (42961, control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; complicated, requiring hospitalization).

In this situation, only the admission would be charged. The consult is considered part of the initial hospital visit (99221-99223).

If the otolaryngologist sees the patient in the ED on day one and admits the patient on day two (defined as beginning at midnight), even if fewer than 24 hours has elapsed, an ED visit or consult may be billed for day one and an admission billed for day two, according to the MCM.

The same rules apply for admitting a patient to observation. But the place of service must be specified and must agree with the hospitals own documentation regarding the patient.

Note: If a patient is admitted (either to hospital or observation) and then discharged on the same day, codes 99234-99236 should be used.