Otolaryngology Coding Alert

Question: The otolaryngologist is on call for the emergency department (ED). He sees a 5-year-old boy for epistaxis. The otolaryngologist wants to bill 99243 (Office consultation for a new or established patient, detailed history and examination and medical decision-making of low complexity). Is this the correct code for a consultation in the ED?

Nevada Subscriber

Answer: Codes 99241-99245 are correct for true consultations that occur in the ED. Many otolaryngologists and coders mistakenly believe that outpatient consults should be used for office visits only. In fact, such consultations may occur in any outpatient environment.

The introduction to "Office or Other Outpatient Consultations" in the CPT manual states that 99241-99245 "are used to report consultations provided in the physician's office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care or emergency department."

A consultation, however, may be reported only when certain criteria are met. The real question is: Did the emergency physician request the opinion of the otolaryn-gologist, or did the ED physician hand the patient over to the otolaryngologist? To report any consultation, there must be a request for an opinion by the treating physician. If, as is often the case in the ED, the otolaryngologist took over care without rendering an opinion, a consultation should not be billed.

If the criteria for a consultation are not met, another code must be chosen. The Medicare Carriers Manual clearly instructs physicians who perform services in the ED to report the appropriate-level ED code (99281-99285, Emergency department visit ), even if an ED physician also has seen the patient.

Nonetheless, many carriers do not accept ED codes from two physicians regarding the same patient. And many coding specialists advise physicians that in such cases the appropriate new or established patient code (99201-99215) should be reported instead.

Although new and established patient codes are appropriate because the ED is an outpatient location, established patient codes reimburse at a significantly lower rate than ED codes (0.94 for 99213 vs. 1.64 for 99283). You may need to appeal ED code denials to reinforce to carriers that physicians other than the ED physician are supposed to use these codes.