Otolaryngology Coding Alert

Question: A patient presents to my otolaryngologist for a right neck mass after an emergency department (ED) physician advised the patient to see an ENT. Should I report the office visit as a consultation?

Missouri Subscriber

Answer: To report a consultation (99241-99245, Office consultation for a new or established patient ...) after the ENT encounter, the ED physician must assume the patient's care, which would complete the circle of care that the consultation codes require. The circle begins when the ED physician asks for the ENT's opinion. The ENT then sees the patient and issues a report of his findings, which he sends to the ED physician. After the ENT treats the current problem, he sends the patient back to the ED physician, so no transfer of care occurs and the circle is complete. Presumably an ED physician would not assume patient care, thereby voiding the circle of care. So, under strict interpretation of the consultation requirements, the encounter does not qualify as a consultation.

Some coders favor a looser interpretation in this case, which allows the primary-care physician (PCP) to complete the circle of care. For instance, the ED doctor may indicate that the patient needs an ENT's opinion after which the PCP will resume care of the patient. Although the care circle varies from the strict model, you may argue that the PCP's resumption of care completes the circle.

To see whether the ENT encounter counts as a consultation, check whether the ENT's documentation supports that conclusion. Suppose the ENT writes: "Patient sent to me by Dr. ED for my opinion on right neck mass." In addition, the ENT sends a letter of his findings to the PCP (with a copy to the ED physician) and indicates that he will discharge the patient back to the PCP when care for the mass is done. In this case, a circle of care occurs, so you could argue that the ENT encounter was a consultation.

On the other hand, suppose the ENT's notes read: "Patient referred to me by Dr. ED for right neck mass." The ENT does not send a letter to the ED physician, who does not care about patients who move through the ED. Because the ENT does not document a request, this scenario qualifies as an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...), rather than a consultation (99241-99245).