Otolaryngology Coding Alert

Better way: Let the problem drive your E/M code selection When claiming 99215 based on a comprehensive history and examination, make sure medical necessity underlies these components - otherwise, you could be gaming the system. Medical Necessity Should Dictate the History When you determine a visit's history, the type - problem-focused, expanded problem-focused, detailed, comprehensive - that the otolaryngologist claims must be medically necessary based on the encounter. "The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s)," states CPT's E/M guidelines' section "Instructions for Selecting a Level of E/M Service".

Even though a nurse may take the information necessary to support a comprehensive history, the physician's clinical judgment and the patient's problem should determine the amount necessary. "There's certainly nothing wrong with obtaining a comprehensive history," says Hayes H. Wanamaker, MD, an otolaryngologist at Central New York Ear, Nose & Throat Consultants in Syracuse. But always doing so may not be the best use of your staff's time.

Why: Taking a high level of history can be time-consuming. It's probably not worth the time it takes to obtain a comprehensive history unless the patient or problem are complex, Wanamaker says.

Example: An ENT sees an established patient for cerumen removal. In this case, little medical need exists to take a comprehensive history, Wanamaker says.

In fact, claiming a comprehensive history for such a simple problem could be unethical. "Payers and auditors may view such conduct as 'gaming the system' - obtaining a higher-level component than medically necessary just to charge a higher-level E/M service," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J.

Bottom line: "Routinely claiming a comprehensive history for a simple problem makes otolaryngologists look unprofessional," Wanamaker says.

Exam's Extent Depends on Problem You also have to consider medical necessity when determining the E/M service's exam type - problem- focused, expanded problem-focused, detailed or comprehensive. CPT's instructions on selecting the exam type echo its history component guidelines. "The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s)," states CPT's E/M guidelines.

Translation: A physician's decision to perform a comprehensive exam should stem from the patient's problem(s). Simple problems don't warrant this component level or the physician's time.

Example: An otolaryngologist performs a comprehensive exam for an established patient's follow-up pressure-equalizing (PE) tube check. Performing and claiming this exam level for such a simple problem is inappropriate, Wanamaker says.

Other examples that may not warrant a comprehensive exam include an established patient visit for:
  cerumen removal
  uncomplicated chronic otitis media (OM) (such as 381.1x, Chronic serous otitis media). Taking a comprehensive exam when the [...]