Otolaryngology Coding Alert

Question: What is the proper inpatient code for a patient whom another physician admitted for neck swelling and tenderness on Oct. 1? An internist asked our otolaryngologist to see this patient on Oct. 5 (new patient to our practice). My physician wants to bill an E/M and an incision and drainage (I&D) that he performed on the same day.

Should the ENT bill a consult 9925x? He did the I&D and did not just offer his opinion to the admitting doctor. The ENT did not take over care or discharge the patient.

If not, which E/M code should I use? Code 9920x is for new patient outpatient services, which is not appropriate. The only other code is subsequent care, which doesn't seem right because this was the otolaryngologist's initial visit with the patient.

Virginia Subscriber

Answer: At the time of the consultation, the consultant may initiate diagnostic and/or therapeutic services, so just because the ENT performed a procedure does not alone exclude a consultation code.

The bigger question is whether the ENT assumed care. You indicate he did not, and the internist continued to care for the patient in the hospital. This return of care to the initiating physician helps support a consultation code. Of course, the ENT must fulfill the other inpatient consultation code (99251-99255, Inpatient consultation for a new or established patient ...) requirements of a request for opinion of a medically necessary reason in the patient's shared medical chart, rendering of services (fulfilled), and a report back to the requesting physician (once again in the shared medical record) -- reason and return of the patient are the two new R's introduced in 2006 by CMS and coding experts, respectively.

Alternative: If the pre-I&D encounter does not meet consultation criteria, you should bill subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...). Although providing subsequent care without initial care does not seem logical, no code exists for new patient post-admission care on the inpatient side.

To avoid a concurrent-care denial, make sure you list a different diagnosis than the one the internist reports. If you do receive a denial, appeal the determination with two facts:

• A different specialist provided care for a separate diagnosis.
• Your care was medically necessary because the internist could not provide the same care.

Watch out: The corresponding E/M service modifier changes depending on the I&D code. The 2007 Medicare Physician Fee Schedule assigns 10 global days to 42300 (Drainage of abscess; parotid, simple) and 90 global days to 42305 (... parotid, complicated).

So for an E/M that is significant and separate from the I&D, you should use modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the service code, such as 9925x.

To report an E/M and complicated I&D, you should instead attach modifier 57 to the service code to indicate -an evaluation and management service that resulted in the initial decision to perform the surgery,- according to CPT's Appendix A -- Modifiers.