Otolaryngology Coding Alert

Look at the result location, patient's status for box 24B entry

Use this pop quiz to stop incorrect place-of-service (POS) codes from dead-ending your sleep study and observation claims.

Sleep Study Interp Locale Determines POS

Question 1: Our otolaryngologists are certified to interpret sleep study results (95807-95811) at a local hospital-owned sleep lab. Our physicians do not see the patients; they only interpret the test results. Which POS should I use?

Answer 1: The answer depends on where the otolaryngologist performs the service, says Terri Fischer, CPC, CMC, manager of Health Care Group at Larson, Allen, Weishair and Company LLP in St. Louis, Mo. If the otolaryngologist interprets the results in the hospital, you should report 95807-95811 with POS 22 (Outpatient hospital). If the physician is interpreting the test in your office, report POS 11 (Office).
 
Pitfall: Make sure you don't bill the global sleep study code (95807-95811) in this situation. You should instead report the code with modifier -26 (Professional component), says Jill M. Young, CPC, president of Young Medical Consulting in East Lansing, Mich. "Because the hospital owns the sleep lab and the otolaryngologist is doing only the interpretation, you should report only the professional component."
 
Example: A physician orders a polysomnography including sleep staging with electrocardiogram (ECG), airflow and ventilation, and respiratory effort. The hospital-owned sleep lab faxes the test results to an otolaryngologist who completes the written interpretation, diagnoses sleep apnea and sends it back to the facility.
 
You report the polysomnography with three additional parameters of sleep as 95808 (Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist). To indicate that the otolaryngologist performed the interpretation only, append modifier -26 to 95808. You would assign the sleep apnea diagnosis, such as 780.53 (Hypersomnia with sleep apnea).
 
Don't forget: Indicate that the otolaryngologist performed the interpretation in the office by placing an "11" in box 24B on the CMS 1500 form.

Observation Equals Outpatient Status

Question 2: An otolaryngologist admitted and discharged a patient to observation status for 12 hours in the emergency department. We reported the service as 99235 with POS code 23 (Emergency room - hospital). The carrier told us to use 22 (Outpatient hospital) instead. Why?

Answer 2: "If you're going to bill an observation code, the place of service is 22," says Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., in Spring Lake, N.J. Make sure that "observation" noted in a patient's chart means the patient was under observation status. If the physician did not officially place the patient "under observation," the service does not warrant an observation service code, and POS code 22 may not be appropriate, Brink says.
 
Reason: The patient's status - not his physical location - determines the POS. Even though the patient is physically in an ED, when the otolaryngologist registers him to observation status he is considered a hospital outpatient. The physician can perform observation anywhere: in a room, a clinic or a hallway.
 
Watch out: Double-check your observation code. You should use 99235 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...) if the otolaryngologist admits and discharges the patient on the same date. But if the 12-hour observation occurs on different dates, you should instead report the admission with 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient ...) and the discharge with 99217 (Observation care discharge day management ...).
 
Medicare alert: Carriers may want you to use 99218-99220 for same-day observation admits and discharges. "If the patient is discharged on the same date as admission to observation, pay only the initial observation care code because that code represents a full day of care," states the Medicare Claims Processing Manual, Chapter 12, section 30.6.8.B. Therefore if an otolaryngologist provides 12 hours of observation care on the same date, Medicare would expect to see only a code in the 99218-99220 range, not 99234-99236.
 
The Medicare Fee Schedule, however, does designate 99234-99236 as active codes.