Otolaryngology Coding Alert

Question: I am an ENT located next door to the hospital. Frequently primary-care physicians will request consultation with patients diagnosed with dizzy/vertigo. We can only do a brief evaluation of the patient at this hospital. There isnt equipment available within the hospital to do an audio workup. Usually we have the patient brought to our office next to the hospital where the equipment is available. The only problem with this is Medicare will not pay for these tests, indicating they were rendered in an inappropriate or invalid place of service. Is there any other way we can render these services and get paid from Medicare?

Robin Laxton
Lenoir, N.C.

Answer: Patients being seen in consult in an outpatient, inpatient, or emergency room status would be billed to Medicare with the appropriate consult code and appropriate location code. Tests performed in an outpatient clinic on patients from the emergency room or outpatient status would be billed with a location code for outpatient clinic. Medicare should not have a problem paying for these services since they could be performed prior to or after the hospital visit. However, tests performed in an outpatient clinic on a patient who is an inpatient at the time of service may pose a billing problem, says Cindy McMahan, CPC, a coding and reimbursement specialist at SVA Consulting in Albany, Wis., as the patient has not been discharged and there is no reason for Medicare to pay for an outpatient service performed during an inpatient stay.

Due to the fact that the hospital does not have the equipment needed for an extensive audio workup and you as a specialist determine the medical necessity of the tests, you should be reimbursed for your services, McMahan says.

I would suggest that you contact the hospital administration and research the possibility of contracting with the hospital for the performance of the tests and the use of your equipment. If such a contract were developed, the hospital would include the charges for your service and the use of the equipment in their charges to Medicare for the inpatient stay. Medicare should pay the charges since the patient remained in inpatient status. You would be reimbursed by the hospital for your services and equipment usage. Hospitals contract with other providers of services and equipment in this manner, and there should be no reason for it to be a problem for you to do the same, says McMahan, adding that you should remember to verify this coverage with your Medicare carrier.