Otolaryngology Coding Alert

Question: What level of E/M should be reported when the nature of the patient's problem is at level three, and the otolaryngologist takes a comprehensive history and performs an expanded problem-focused examination and straightforward medical decision-making?

Rhode Island Subscriber

Answer: Only three factors must be considered at any time history, examination and medical decision-making. The nature of the problem (chief complaint/history of present illness) is a component of the history and should not be assessed on its own.

The ultimate level you should select depends on the type of E/M service being billed. For new patient visits and consults, all three components must be taken into account; therefore, the lowest of the three determines the E/M visit's level. In this case, for example, both the medical decision-making and the examination qualify for a level-two new patient visit or consult. Even though the history taken qualifies for a level five, only a level-two new patient visit (99202) or outpatient consult (99242) may be billed.

For an established patient office visit, however, only two of the three factors need to be considered. Furthermore, the expanded problem-focused examination is considered a level-three exam. Therefore, a level-three established patient visit (99213) may be reported, because only the two highest components are considered, and these are the level-five history and the level-three examination. The lower of these two determines the level that may be billed.

The nature of the problem plays a role in determining the visit's level. For example, a patient presents for a follow-up exam for allergic rhinitis (477.0). Although the physician takes a comprehensive history and a comprehensive examination and orders lots of tests to support high decision-making, the medical necessity of the visit does not support a level four or five. The doctor, not the coder, must determine if the nature of the problem warrants a higher E/M level.

You Be the Coder and Reader Questions answered by Randa Blackwell, financial specialist with the otolaryngology division of the department of surgery at the University of Maryland in Baltimore; Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.; Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J.; Tara Kaye, appeals coordinator with Atlanta ENT, a large otolaryngology practice with offices throughout metropolitan Atlanta; Melissa Pointer, CPC, billing manager with the otolaryngology division at the University of Arkansas for Medical Sciences in Little Rock; and Teresa Thompson, CPC, an otolaryngology coding and reimbursement specialist in Sequim, Wash.