Otolaryngology Coding Alert

Hint: Your ENT's recs are the ones to count under mgt options.

When a patient has an E/M in which your ENT recommends the patient undergo a major surgery subject to a PCP preop exam, don't scratch your head over the applicable table of risk selections " focus on your doc's role.

Test your major versus emergency surgery savvy and who gets the credit for surgical recommendations with this case.

A 45-year-old patient fell from a ladder (E881.0), hit a fence on the way down, and fractured his nose (802.x). My otolaryngologist evaluated the patient's nose and scheduled the patient for surgery for an open reduction of the nasal fracture (21325, Open treatment of nasal fracture; uncomplicated). Although the patient has no known risk factors, the ENT requested a preoperative clearance exam from the patient's family physician due to the patient's head injury incurred during the fall. The ENT takes the patient into the OR in the following 24 hours. Regarding my physician's E/M, I have two auditing questions:

1. Do Details Count as HPI?

Should you count the accident's details ("on a ladder," "hit a fence") as context in history of present illness (HPI)?

Answer: You can count either the phrase "on a ladder" or "hit a fence" as context for history of present illness (HPI). Context is what the patient was doing when the injury/condition/illness occurred. The physician receives credit for context only once, regardless of the number of details documented. If the physician documented when the fall happened, you can count "Duration" in the HPI as well. If there is a comment in the note such as "the patient indicates that the nose is throbbing," this can be counted as "Quality."

2. Is This Emergency Surgery?

"Under the Table of Risk, should I consider this emergency major surgery?" the auditor asks. While her physician is the one evaluating the injury (99201-99215, Office or Other Outpatient Services), making the decision for surgery (modifier 57), and performing the procedure, he is not determining the patient's suitability for surgery. "Is there any published guideline to differentiate between 'elective' and 'emergency' major surgery, as well as who can count it?" wonders the coder.

For Management Options Selected, attribute any surgery to the recommender. "Since the surgeon was the one that recommended surgery, the Management Options Selected in the Table of Risk is attributed to the surgeon," says Suzan Berman, CPC, CEMC, CEDC, Senior Manager of Coding Education and Documentation Compliance Physician Services Division UPMC-Pittsburgh.

When selecting the FP encounter's level of risk, do not count the surgical management option, as the FP isn't doing or hadn't been the one to recommend the surgery. "To determine the level of risk associated with the FP's preoperative clearance encounter with the patient, the FP could count Presenting Problem(s) that are examined within the Table of Risk," Berman points out.

Apply Your Knowledge

Let's apply the emergency and risk factor definitions to the pre-op clearance scenario. "Open fracture reduction 24 hours after surgical clearance would not be emergency surgery," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, manager of compliance education with University of Washington Physicians. "Emergency surgery is surgery that must be performed immediately."

Solution: Both the ENT and the FP would have a moderate level of risk for their respective encounters with the patient. Here's why:

The surgeon would have a moderate level of risk for selecting the elective surgery without identified risk factors. "Very typically, clearance for surgery would result in the decision that the patient could have elective major surgery without identified risk factors," Bucknam adds.

The FP would have to rely on the presenting problem(s) evaluated. In this case, the presenting problem is an acute complicated injury, which is a moderate level of risk.