Otolaryngology Coding Alert

Question: We have a father and a son scheduled for surgery on the same day. The wife/mother has scheduled an office appointment with my doctor prior to the surgery to go over the procedures and to be counseled on post-operative care for both patients.

When I called the carrier to find out how it would consider this situation, I was told that the wife/mother becomes the patient and advised to code for a consultation. This, however, makes no sense because we will not have a diagnosis code for her. Can you help?

Nebraska Subscriber

Answer: The visit by the wife/mother may be payable, depending on the age of the son. The visit should not be billed as a consult because there is no requesting physician, says Elaine Elliott, CPC, an independent coding and reimbursement specialist in Jensen Beach, Fla.

Normally, conversations with family members take place either during the evaluation and management (E/M) visit that led to the decision to perform surgery or shortly before the operation. If the counseling occurs during the initial visit, the time spent should be documented and considered when calculating the level of the visit. On the other hand, if the wife/mother was counseled on the day of or the day before surgery, no E/M service should be billed because it is included in the global package of the procedures.

In this case, however, the counseling appears to have occurred at some point in between. If the physician counseled the wife/mother only about the husbands condition and treatment, the visit would not be payable, because the husband was not present and, therefore, no face-to-face time with the patient can be documented.

But if the otolaryngologist counseled the wife/mother about her son, and the son is a minor, the mother is considered to be acting on his behalf. In this case, an established patient visit could be billed (9921x) with time as the main factor because more than 50 percent of the visit was for counseling. Only the time spent discussing the sons condition and treatment should be considered when calculating the level of the visit. If the otolaryngologist decides to follow the carriers suggestion to bill the meeting as a consult, obtain the advice in writing to protect your practice if the claim is questioned in an audit.