Otolaryngology Coding Alert

Question: Our payers always deny our claims with 99283 or 99284, even though we’re reporting a legitimate service. Our physicians sometimes are called to the ER to see a patient and consult with them. Then the patient could be discharged and go home. Should I be using 99213 with the appropriate place of service 23 instead?

New York Subscriber 

Answer: If the physician tells the patient to go to the emergency room, you should report a service code from the 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) series. If the physician was asked to see the patient in consultation, the 99241-99245 (Office consultation for a new or established patient …) series is what you should use if your payer does not pay ER codes 99281-99285 and allows you to use consultation codes. Medicare would ask you to submit 99201-99215 (Office or other outpatient visit for the evaluation and management …). Your place of service does not change. You are in the ER and you should use POS 24 for the ER.  Office and Outpatient codes are appropriate for ER place of service.

In the non-Medicare case, you would code 99241-99245 for the consultant services. The level of consultation is based on the documentation in the medical record and the documented problem(s) establishes medical necessity for the consultation.

Payer rules will often dictate the code series used. Some may prefer to use 99281-99285 (Emergency department visit…) for a visit and the consultation codes for a consult.