Otolaryngology Coding Alert

Nurses billing phone calls, e-visits and team conferences is no longer a "no-no." Get the facts on the new MD-E/M codes and their nonphysician counterparts so you can help your otolaryngologists evaluate your practice's 2008 E/M coding policies.

Although payment hurdles may stop you from reporting telephone services, new codes -- if you use them -- will be easier to assign. CPT 2008 deletes complexity-based telephone call codes (99371-99373, Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other healthcare professionals ...) and introduces two sets of time-based telephone services codes:

Benefit: "I think that time-based reporting versus trying to determine what is -simple,- -intermediate- or -complex- is definitely a good thing," says Denae M. Merrill, CPC-E/M, coder for Covenant MSO in Saginaw, Mich. "You then have a clear-cut definition of what is what. A provider will then know what is important to document, and a coder will know what code is most appropriate, and there will be no room for arguing."

Rules: Before reporting a telephone service, adhere to two global periods:

1. Seven-day pre-global: If an otolaryngologist treats a patient for a problem in the office and then discusses the problem with the patient on the phone in the next seven days, you would not bill the telephone service with 99441-99443.

2. 24 hours or soonest available appointment post-global: If an ENT provides a telephone E/M service and then sees the patient for the same problem within 24 hours or the next available visit, you forfeit the call code. You would report only the E/M service, such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient -). The idea is that the phone call should prevent in-office treatment.

If you don't now report telephone services, the three new codes may make you reconsider your policy. CPT 2007 limited telephone care to physician-performed calls, which depending on state scope of practice also apply to nonphysician practitioners, but CPT 2008 opens the door to qualified nonphysician healthcare professionals reporting telephone services with 98966-98968. Payers may vary on eligible providers, says Quinten A. Buechner, MS, MDiv, ACS-FP/GI/PEDS, CPC, CCP, CMSCS, president of ProActive Consultants LLC in Cumberland, Wis.

Example: An established patient with a history of colds leading to sinusitis calls his otolaryngologist to discuss new acute sinusitis symptoms. The nurse obtains a history via telephone, assesses the patient's condition, and talks to the ENT, who decides to prescribe an antibiotic. The nurse-to-patient call lasts 15 minutes. In 2008, you could use 98967 (- 11-20 minutes of medical discussion) based on time and personnel, rather than on complexity.

The big question for practices, however, will remain: Will payment make reporting the new telephone service codes worthwhile? Medicare has historically not covered non-face-to-face services.

But that doesn't rule out private payers or charging patients if the policy considers the telephone service noncovered. "We document the service, bill to the insurance company, and then let them deny it. Then we write it off if it is an insurance company we participate with," says Wendy L. Coito, practice manager with Maine Otolaryngology Surgery Associates in Belfast. "It is a principle thing for our practice as well, as we bill for what services we provide so that we might utilize these denials in the future, for example, in contract negotiations."

Good news: CMS published relative value units (RVUs) that you can use as a payment guide for non-Medicare plans. Ask your major payers about reimbursement, Buechner says. "Payers are likely to be all over the map and may not really decide until March."

The 2008 Medicare Physician Fee Schedule assigned the same transitional nonfacility total RVUs to the physician and nonphysician healthcare professional codes. Minute-to-code breakdowns and personnel include the following:

5-10 99441 98966 0.35

11-20 99442 98967 0.66

21-30 99443 98968 0.98

Another non-face-to-face service coming into its own in 2008 is an "e-visit." Online E/M visits, consultations and Web visits all fall under the term "e-visit," which is a structured non-urgent consultation between a doctor or nonphysician practitioner and an established patient conducted over the Internet.

Change: Because online service is no longer considered an "emerging technology" (temporary Category III codes), the AMA made it a Category I service. CPT 2008 deletes the 2004-created CPT category III code for online evaluation: 0074T (Online evaluation and management service, per encounter, provided by a physician, using the Internet or similar electronic communications network, in response to a patient's request, established patient). In 2008, you-ll instead use one of two provider-dependent codes:

- If your otolaryngologist provides an e-visit, you can use 99444 (On-line evaluation and management service provided by a physician to an established patient, guardian, or healthcare provider not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network).

- When a nonphysician practitioner provides the service, use 98969 (On-line assessment and management service provided by a qualified nonphysician healthcare professional to an established patient, guardian, or healthcare provider not originating from a related assessment and management service -).

As with telephone service codes 99441-99443 and 98966-98968, you should apply 99444 or 98969 only if the e-visit is unrelated to any previous service within the past week. Also, be sure that the physician develops separate documentation to show that the e-visit is significant and independent of other recently provided services.

You would only report the telephone service or online service if it took the place of a visit, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga. "Many insurance payers have not embraced this service for reimbursement, and there are technology requirements (HIPAA-compliant network, retention of online conversation in permanent patient record, etc.) that also have to be met." The 2008 Medicare Physician Fee Schedule assigned both 99444 and 98969 no RVUs.

In 2008, you-ll look at more than time when coding medical team conferences. The AMA deleted the two team-conferences codes (99361, Medical conference by a physician with interdisciplinary team of health professionals or representative of community agencies to coordinate activities of patient care [patient not present]; approximately 30 minutes; and 99362, - approximately 60 minutes). When choosing between the new team conference codes, zoom in on the provider and the patient.

If the conference involves the otolaryngologist, you-ll use 99367 (Medical team conference with interdisciplinary team of healthcare professionals, patient and/or family not present, 30 minutes or more; participation by physician). In this case, the patient and/or family are not present.

"Codes 99366 and 99368 were added to allow inclusion of nonphysician, qualified healthcare professionals," says Susan E. Garrison, CHC, PCS, FCS, CCS-P, CPAR, CPC, CPC-H, executive vice president of Healthcare Consulting Services.

If the patient and/or family is present for the conference, choose 99366 (Medical team conference with interdisciplinary team of healthcare professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified healthcare professional). When the patient and/or family do not attend the meeting, use 99368 (Medical team conference with interdisciplinary team of healthcare professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified healthcare professional).

You won-t, however, have to do one thing that you had to with the 2007 team conferences codes: code based on time. The new codes are open-ended, for "30 minutes or more," meaning you will code the conference only once regardless of its length.

Patient presence matters: Because many payers, including Medicare, will not reimburse separately for non-face-to-face services, insurers will likely not recognize 99368 (during which the patient and/or family is not present) as a payable service. But payers may accept 99366 if a nonphysician in your practice takes part in a team conference involving the patient and/or family. The codes contain 1.08, 1.40 and 0.91 RVUs, according to the 2008 Physician Fee Schedule, which also assigns them a bundled status.

Reporting advice: Documentation will be key when reporting team conferences, Garrison says. She suggests that for each service, physician notes should specify:

- Who participates in the conference (the specific providers with credentials). Remember, only one same-specialty, same-practice professional may bill per conference.

- Time of participation. This must begin at the start of the review for an individual patient and ends when that review is concluded. The service must deal with one patient at a time.

- The patient's presence (or lack thereof).

- Plan going forward to include:

a. treatment goals

b. what rehab treatment is prescribed (be specific)

c. any referrals.