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 postoperative care for both patients. How should I report the wife/mother's visit?

Nebraska Subscriber

Answer: The physician usually talks to family members during the 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. However, if the counseling occurs 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 your scenario, the counseling appears to have occurred at some point in between. If the physician counseled the wife/mother about the husband's condition and treatment only, 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 acting on his behalf. You should bill an established patient office visit (9921x) using time as the main factor because more than 50 percent of the visit was for counseling. Only the time spent discussing the son's condition and treatment should be used to calculate the level of the visit.