Otolaryngology Coding Alert

Question: An established patient arrived for a scheduled visit and the doctor performed a level-four office visit (99214). As a result of the exam, the physician referred the patient to the hospital for a chest x-ray. While at the hospital, the patient collapsed and was admitted to the ICU. Our doctor was called to perform an inpatient consult (99254). Can we bill both services and, if so, do we need to use a modifier?

Kansas Subscriber

Answer: The answer depends on why the patient collapsed and had to be taken to the intensive care unit (ICU), says Michelle Logsdon, CPC, CCS-P, a coding and reimbursement specialist in Bayville, N.J. If the collapse is related to the condition that brought the patient to the doctors office for the consult, a second evaluation and management (E/M) code should not be billed because, in most circumstances, only one E/M code may be billed per patient per day.

The physician deserves to be paid his or her additional time, however, and should seek reimbursement by billing for prolonged services. Assuming the physician documented time for both services and the total time for the services was at least 110 minutes (80 minutes is the reference time for 99254, and 30 minutes is the minimum needed to bill the first hour of prolonged services), he or she should bill for the inpatient consult (99254) and for 30 minutes of prolonged services using 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour [list separately in addition to code for inpatient evaluation and management service]) instead of 99214.

Note: All 110 minutes must documented in one of the two charts for the physician to bill.

On the other hand, if the patients condition is due to an unrelated condition, the consult and the established patient visit may be billed separately. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to indicate that the second E/M is an unrelated problem.

Such a claim is unlikely to be paid on first submission and will need to be appealed, Logsdon says.

Note: Although Medicare carriers, in particular, should not require two diagnoses in most cases when modifier -25 is used, when two E/M services are provided on the same day the two diagnoses provide medical necessity and therefore should be included.