Otolaryngology Coding Alert

You-ve been on the fence for two years now on consultation coding for a specific problem, and CPT 2008 didn't answer any of your questions. But you can confidently code a consult despite the "transfer of care" language if the encounter passes this litmus test.

In 2006, CMS redefined a transfer of care as one that occurs "when a physician or qualified NPP [nonphysician practitioner] requests that another physician or qualified NPP take over the responsibility for managing the patient's complete care for the condition and does not expect to continue treating or caring for the patient for that condition." The revision caused confusion over whether cases in which an ENT sees a patient at the request of a physician for care of a specific condition could qualify as a consult. "The answer is yes and no," says Patrice Morin-Spatz, coding expert with MedBooks in Richardson, Texas.

Solution: "It's yes if the scenario can pass this two-prong test," says Morin-Spatz, past-editor of the AMA's CPT Book. When considering a consultation code, ask

1. When is the diagnosis reached?

2. When did treatment begin?

Key: You may consider the visit a consultation when the diagnosis or the treatment is not known, provided the requesting physician words the request for opinion appropriately. Documentation should show that he asks for either a diagnosis and/or a treatment plan.

Apply the above two questions to this scenario: A pediatrician sends a patient who has had frequent ear infections to an ENT for possible ventilating tube insertion.

Does the initial visit's request qualify as a consult? "It depends on what the pediatrician is asking for in his request to the ENT," Morin-Spatz says.

The visit can qualify as a consultation if the pediatrician knows the condition and is asking for the ENT's opinion relative to a treatment plan, Morin-Spatz says.

Example 1: The pediatrician's request states, "I think my patient may be a candidate for ventilating tube insertion. I-m sending him to you for your opinion on possible treatment options."

In this case, the diagnosis is known, but the treatment hasn't begun, Morin-Spatz says. "Therefore, the ENT is truly rendering an opinion." If the initial ENT encounter meets the other consultation criteria including a report back to the pediatrician, you may code the visit with 99241-99245 (Office consultation for a new or established patient -).

Best practice: The ENT can further stress that he rendered an opinion by using "requesting" terminology in his report, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, consulting editor of publications for the American Academy of Professional Coders in Salt Lake City. A good statement would be, "Thank you for requesting my opinion on Mary Smith's chronic rhinitis," she says.

Requests specifying the treatment may fall short of a consultation.

Example 2: The pediatrician's request indicates, "The patient needs ear ventilating tubes," and there are no more necessary steps in deciding the treatment. The request doesn't meet a consultation's intent for opinion, Morin-Spatz says.

Instead, the report is a transfer of care for a specific condition. "The pediatrician is sending the patient over for PE tubes, and the treatment plan had already been reached prior to the patient workup by the otolaryngologist," Morin-Spatz says. So you would code an office visit (99201-99215, office or other outpatient services depending on whether the patient was new or established).

Remember that CMS has stricter consultation guidelines than CPT. You don't have to apply CMS rules across the board. "When dealing with [non-Medicare] payers, I tend to use the CPT definition," says Donelle Holle, RN, professional fee services manager for the University of Michigan Health Systems.

Using dual consultation coding guidelines means keeping track of which rules to follow with which patients. "When treating the patient, the doctor should not have to worry about what insurance a patient has," Cobuzzi says. Evaluations for possible PE tube insertion mainly involve pediatric, non-Medicare patients. For non-pediatric issues, consider three tactics:

A. Safe way: Implement the stricter guidelines for everyone. This ensures you cover all bases.

B. Color route: Paper offices can put a bright-colored sticker on Medicare charts so that the doctor can be aware of Medicare patients, Cobuzzi says. For non-designated -- private payer -- charts, the physician could code the encounter using CPT guidelines.

C. Policy path: "Research what the individual carrier has adopted as a guideline for consultations, and have the guideline in your office on file," writes Teresa Thompson, CPC, CMSCS, CCC, TM Consulting president, in "Understanding Consults" offered by the American Academy of Allergy Asthma & Immunology.