Otolaryngology Coding Alert

Question: We-ve been receiving concurrent care denials for E/M services our otolaryngologists provide to inpatients. How can I prevent this problem?

New Jersey Subscriber

Answer: When your ENTs submit the same services another physician group has charged, the insurer's system edits will kick out the subsequent claim. ICD-9 codes are the key to avoiding these rejections.

Make sure your diagnosis reflects the condition(s) your ENTs are treating. You may need to contact the other groups- coders to ensure they code based on the same rule.

Example: An internist admits a patient to the hospital for diabetes and hypertension. The patient later develops parotitis and severe headaches. The internist asks an ENT to treat the patient's parotitis and asks a neurologist to treat the patient's headaches.

For all physicians to get paid for their respective services, each must use the code for the condition he treats. The ENT must use parotitis (527.2, Sialoadenitis) with subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the E/M of a patient). The neurologist must link the headache diagnosis (e.g., 784.0) to his claim for 9923x. The internist should report the admission (99221-99223, Initial hospital care, per day, for the E/M of a patient -) with diabetes (e.g., 250.02, Diabetes mellitus without mention of complication; type II or unspecified type, uncontrolled) and hypertension (e.g., 401.1, Benign essential hypertension).

Tip: Tell your ENTs that they can help you overturn any future concurrent care denials. Encourage them to clearly state in their documentation that they aren't treating the patient for the same problem as the other physicians, such as the internist and neurologist.

For instance, documentation in the above case should explain that the internist admitted the patient for diabetes and hypertension, but during the course of his hospitalization he developed parotitis and headaches. At that time, your ENT began treating the patient's parotitis, not diabetes, hypertension and headaches.