Otolaryngology Coding Alert

"As long as the documentation includes a written request for a consultation and the otolaryngologist's written report to the primary care physician (PCP), the otolaryngologist can bill the appropriate consultation code," says Randa Blackwell, coding and reimbursement specialist with the department of otolaryngology at the University of Maryland in Baltimore.

If the otolaryngologist performs a procedure after seeing a patient at the request of another physician, the visit may still be a consultation if:

Note: Some carriers may not follow these recommendations and may request different (or no) modifiers.

Three series of consultation codes exist:

Scenario 1: Suspecting hearing loss, a family physician orders a screening audiogram for a 72-year-old patient. The PCP sends the patient to an otolaryngologist for more tests. The otolaryngologist examines the patient and performs additional tests to define the cause of the hearing loss.

Because treatment was uncertain when the patient visited the otolaryngologist, you should code an outpatient consultation (99241-99245) if the requesting physician requested the otolaryngologist's opinion in writing, the request is noted in the patient's medical record, and the otolaryngologist provides the PCP with a written report. The testing should be billed separately (probably 92557, Comprehensive audiometry threshold evaluation and speech recognition [92553 and 92556 combined]).

Scenario 2: A patient with respiratory problems related to a cardiovascular incident is admitted to the hospital by his attending PCP. The internist is unsure if the patient requires a trach, so an otolaryngologist is called in. The otolaryngologist determines that the trach is not necessary at this time because the patient is ventilating well and has satisfactory oxygen levels.

Even though the patient has already been diagnosed, the PCP wants the otolaryngologist's opinion on how best to treat the patient. Therefore, the otolaryngologist may bill the appropriate-level initial inpatient consultation code if there is a written request in the patient's chart for the otolaryngologist to see the patient.

A separate report is not required in the hospital setting, according to section 15506 of the Medicare Carriers Manual (MCM), which states: "The request for consult may be documented as part of a plan written in the requesting physician's progress note, an order in the medical record, or a specific written request for the consultation."

Scenario 3: This is the same as scenario 2, but the otolaryngologist immediately begins to prepare the patient for trach implantation.

Again, the internist has asked for the otolaryn-gologist's opinion, but this time, because the patient is immediately prepared for surgery, modifier -25 (Modifier -57 may be appended, depending on carrier.) should be appended to the appropriate initial inpatient consultation code. Doing so indicates that the consultation was not part of the preoperative evaluation included in the trach placement (31600, Tracheostomy, planned [separate procedure]) and that the decision to implant the trach was made during the consultation.

Trach procedures have zero global days, which includes any E/M performed up to 24 hours before and the day of surgery. Therefore, modifier -25 should be appended to significant, separately identifiable services, such as the decision to perform the procedure.

Note: The CPT manual states that "only one initial consultation should be reported by a consultant per admission," so any subsequent consultation should be reported using the appropriate follow-up inpatient consultation code. But "if the physician consultant has initiated treatment at the initial consultation, and participates thereafter in the patient's management, the codes for subsequent hospital care should be used (99231-99233)."

Scenario 4: A male patient, 67, is in respiratory failure at a small facility. Laryngoscopy reveals a laryngeal carcinoma. The patient requires a laryngectomy, but the hospital does not have the facilities for such complex surgery, so the patient is transferred to a teaching facility where an otolaryngologist admits the patient and performs the laryngectomy.

Even though the admitting otolaryngologist examines the patient, a consult should not be performed because the decision to perform a laryngectomy was already made at the smaller facility. In addition, the treatment of the patient has been transferred by agreement to the admitting otolaryngologist.

The admission by the second otolaryngologist should be billed, regardless of whether it occurs two or more days before the laryngectomy (as is often the case), or one day before. If the laryngectomy is performed two or more days after the admission, there should be no problems obtaining payment for the admission, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.

Carriers should pay for the admission even if it occurs the day before or the day of surgery, because the otolaryn-gologist has to make the decision for surgery. Modifier -57 should be appended to the appropriate E/M service if it is performed the day of or a day before surgery.

Any scopes performed prior to surgery may also be reported separately using the appropriate laryngoscopy code, Cobuzzi adds.

The MCM states that "if the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are met." But situations occur when a consultation should not be billed.

Scenario 5: A 3-year-old boy arrives at the ED with a suspected foreign body. The emergency physician examines the child, then calls in the otolaryngologist, who also examines the boy. After looking at the film, the otolaryngologist determines the boy has a severe upper respiratory infection, not a foreign body. The otolaryn-gologist discusses his findings with the ED physician, who calls in a pediatric internist to treat the child.

A consultation can be billed because the otolaryn-gologist was called in for advice and the patient's care was not transferred to the otolaryngologist.

Because the otolaryngologist's examination occurred in the ED, which is classified as outpatient, the appropriate outpatient consultation code (99241-99245) should be reported. To avoid subsequent audit problems, you should include the full name of the emergency physician in the patient's medical record.

Note: When dictating a consultation report or, in the case of the requesting physician, a request for an opinion, you should avoid use of the word "referral" because many carriers take this to mean that a transfer of care has occurred. The attending physician should be referred to as such, or as the requesting physician, otherwise your carrier may assume that the otolaryngologist has taken over care of the patient who was "referred."

Ann Hughes, CPC, a practice coder with Mid-Vermont ENT in Rutland; and Teresa Thompson, CPC, an otolaryngology coding and reimbursement specialist in Sequim, Wash., also contributed to this article.