Otolaryngology Coding Alert

Question: An otolaryngologist had to intubate a patient who was unconscious. What level history can the physician report?

Texas Subscriber

Answer: When a patient is unable to communicate, you may consider the history at a comprehensive level, according to CPT guidelines. The otolaryngologist's documentation should include a statement indicating, for example, "history incomplete due to patient's condition" or "unable to obtain history because patient is unconscious." The examination should include consistent findings.

Make sure to attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M service, such as initial hospital care (99221-99223) to indicate a significant, separate service from the minor E/M included in the intubation (31500, Intubation, endotracheal, emergency procedure).

Initial hospital care requires the physician meet all three key components. Comprehensive history qualifies for all three levels.

You may also code subsequent care. Code 31500 includes a zero-day global surgery period.