Otolaryngology Coding Alert

Question:

An ENT sees a patient in follow-up for a tympanoplasty (69436, Tympanostomy [requiring insertion of ventilating tube], general anesthesia), within the insurer's 10-day global period for the minor procedure. The physician performs the follow-up, and the mother complains the child is sneezing and has had a clear runny nose. The note indicates, "Chief complaint: Patient presents for tube check and complains of clear rhinitis.

Exam: Ears clear, no fluid. Nasal membranes swollen and red.

Assessment/Plan: This patient has chronic OM that has resolved. She is given a free sample of Astelin for the rhinitis. Follow up here as needed."

Should I charge an E/M service for the new problem?

Washington Subscriber

Yes, the global package includes only postoperative care related to the original surgery. For an E/M service that is unrelated to the surgery, you should report the appropriate level of care appended with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).

Link 99212-24 (Office visit for the evaluation and management of an established patient ...) to the new problem diagnosis " rhinitis (477.9). Do not include any E/M elements related to the postoperative care in the office visit level coded.

If the physician had seen the patient for only a tube check, you would have instead used 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure]) with the reason-for-surgery diagnosis, such as otitis media (381.00-382.9).

The EM note that the physician wrote is very weak, and you might want to educate him about better documentation. In all probability, he looked in the patient's throat and did a more extensive exam as well as took a more extensive HPI. He could have linked the balance of the prior history from an earlier visit to document an interval history and this note would have been much more substantial.