Otolaryngology Coding Alert

Question: An 80-year-old male patient is seen three times within 36 hours in the ER for epistaxis by the ER physicians. He is admitted after the last visit, and an ENT consultation is requested within eight hours of admission. The patient was still bleeding and is found to have a bleeding diathesis and needed unpacking and repacking. Hypertension and diabetes accompany these diagnoses. The total physician time spent on the consultation was 60 minutes, 20 of which was counseling. 1. What diagnosis codes should be used? 2. Is there a consultation service to be reported in this example? 3. Which physician should report the admission service?

James J. Murale, MD
Delray Beach, FL

Answer: The reporting of diagnosis codes will depend on the physician, says Rita Scichilone, MHSA, RRA, CCS, CCS-P, a manager in the coding products and services division of the American Health Information Management Association (AHIMA). The ER treating physician should report the epistaxis code (784.7) since that is why the patient originally came in.

The physician who responded to the request for consultation would report the conditions affecting his or her evaluation of the patient.

1. If the consulting physician was evaluating hemorrhagic diathesis, the correct code is 287.9, without further qualification, with an additional code of 784.7 if the epistaxis was evaluated by the consulting physician. If the cause of the bleeding was determined to be a coagulation defect, then category 286 in ICD9-CM should be reviewed for the condition specified by the consulting physician. The codes for diabetes 250.xx and hypertension 401.x would also be reported if they were evaluated by either physician and had an impact on the management of the patient in either setting.

2. For a consultation code to be reported for a Medicare patient, there should be a documented request in the patients chart for the consultation. After the consult is provided, the consulting physician has to prepare a written report of the findings to the requested physician, which must also be placed in the patients record.

3. According to CPT rules, when a patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service, such as the ER, all E/M services by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The inpatient level of service reported by the admitting physician should include the service related to the admission provided in the other sites of service.

It is not clear who the admitting physician was in this situation. But if the physician providing the consultation service actually admitted the patient eight hours earlier, he or she is an attending physician who should report services with the hospital inpatient service codes (99221-99223). If the subsequent service occurred on a different calendar date, it would be reported with codes 99231-99233 (subsequent hospital care). If another physician, besides the initial physician consult, performed admission services for the patient, that physician would report codes from the 99221-99223 section (initial hospital care). In the unusual
circumstance where the physician providing the ER service also admits the patient, only the codes for initial hospitalization are to be reported, according to CPT guidelines.

If the consulting physician provides an inpatient consultation at the request of another physician, then codes 99251-99255 (initial inpatient consultations, new or established patient) are used with the level determined by the amount of history, examination and medical decision making required.

Twenty minutes of a 60-minute session spent on counseling does not meet the CPT requirement that more than 50 percent of the session be used for time to be the determining factor. More than 30 minutes would need to be spent in counseling or coordination in floor/unit time in the hospital to make time the controlling factor.

Documentation also should be provided that clearly indicates that the consulting physicians opinion was requested and that no transfer of care occurred. If, in fact, a transfer of care did occur, the otolaryngologist would then bill for future visits using a subsequent hospital care code listed earlier.

Of course, any physician rendering cautery or packing procedures to treat epistaxis will report the appropriate CPT code in the range of 30901*-30906*. There are separate codes for initial and subsequent (30906*) treatment, simple (30901*) and complex (30903*) methods and anterial (30903*) and posterior (30905*) technique. CPT modifier -76 (repeat procedure by the same physician) or -77 (repeat procedure by another physician) tells carriers that the procedure had to be performed again.

If the consulting otolaryngologist concludes that the epistaxis must be treated, the consult code used (99251-99255) should be appended with a -25 modifier to indicate a significant, separately identifiable E/M service was performed.

Scichilone emphasizes that physicians must ensure that their documentation supports the medical necessity of more than one physicians services on the same calendar date. This is where diagnosis codes are helpful in distinguishing what role each physician might have had in the patients care.