Otolaryngology Coding Alert

Question: A pediatrician requests that two specialists from my practice, a pediatric ENT and a head and neck otolaryngologist, provide inpatient consultations on different days. The head and neck surgeon incises and drains the parotid on the same day that the pediatric ENT performs a consultation. Due to 42300's 10-day global period, will the consultation be bundled with the procedure?

New York Subscriber

Answer: Without knowing why the primary physician asked each subspecialist to consult, answering your question is difficult. The Medicare Carriers Manual permits multiple consultations from different subspe-cialists within the same group for separate diagnoses, if the visit meets the criteria for billing a consultation. In your case, you should report both consultations if the two otolaryngology subspecialists provide the primary-care pediatrician with opinions on different areas of expertise.

But if the pediatrician asks both providers to consult for the same problem, the payer will probably question why two physicians in the same practice with the same tax ID number are providing multiple consultations. On the other hand, if the head and neck surgeon evaluates facial or neck infection and the pediatric ENT evaluates a separate or different diagnosis, you should bill both consultations.

In this case, you must indicate to the payer that the head and neck surgeon's procedure is different from the pediatric ENT's consultation. Because both physicians bill under the same ID number, this will not be easy.

ENT doctors do not have subspecialty designation codes, so you cannot flag the codes on the claim form. So, from the claim person's perspective, the doctors will appear as the same physician. To alleviate this problem, first file the surgeon's procedure (42300*, Drainage of abscess; parotid, simple) electronically to get a claim number established quickly. Next, bill the pediatric ENT's consultation (99251-99255, Initial inpatient consultation for a new or established patient). Nonetheless, the payer will probably automatically deny the first electronic submission because both claims have the same ID number.

In this case, you will have to file a hard-copy claim and attach a consultation report from the pediatric ENT. Highlight the important parts of the note showing why the pediatrician needed the second subspecialist's opinion. For instance, point out the different diagnoses linked to the procedure and the E/M. Note that the head and neck surgeon evaluated the patient, for instance, for abscess of the salivary gland (527.3), whereas the pediatric ENT treated acute serous otitis media (381.01). Explain why each treatment and diagnosis was out of the other specialist's field of expertise.