Otolaryngology Coding Alert

Why 'significant' and 'separate' matter when you're using modifier -25 Payers are denying claims right and left that don't include sufficient medical-necessity documentation and modifier errors. But performing chart reviews can prevent denials and keep auditors off your doorstep. Support Your E/M Codes When reporting office visits, make sure the documentation supports the E/M service level you've billed, or you could end up returning money to the insurer.
 
"Most practices are overcoding, and their documentation is lacking in the history component," says Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C.

For instance, the appropriate history documentation for a detailed E/M service should include "extended history of present illness" and "pertinent past, family, and/or social history directly related to the patient's problems."
 
Also, the level of medical necessity is critical when you're determining the appropriate E/M code. "Many codes get downcoded because of medical necessity," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.
 
Scenario: The physician bills a level-four established patient visit for treating intrinsic asthma (493.10). You code the visit as a 99214 (Office or other outpatient visit ... established patient). To justify 99214, the documentation should support the medical necessity (medical decision-making of moderate complexity) and at least a detailed history and/or a detailed examination. Also, the office visit should consist of 25 minutes of face-to-face contact with the patient and/or family, according to CPT guidelines. Get the 3 R's You Need for Consults You should report consultation codes (99241-99275) when another physician requests a medical opinion from your allergist, such as when a family practitioner requests your allergist's advice on managing treatment for a patient who is allergic to bee stings.

Otherwise, if a physician asks your doctor to "evaluate and treat" a patient, you should consider this a "referral" and assign new patient E/M codes (99201-99205), Bukauskas-Vollmer says.

Coding challenge: When you're reviewing the consultation you've coded, check your physician's consult documentation to ensure it contains these three key elements:
 
Request: The reason for the consult is always another physician's request for your allergist's opinion, which your doctor should document. "If they request the patient be treated, then it's a referral, not a consult," Jandroep says.
 
Review: When your allergist diagnoses a condition, such as hypertension (401.x), he should document this in the medical notes. A consultation always involves a suspected problem and an unknown course of treatment.
 
Report: The last step is the allergist providing the requesting physician with a report of his findings. Typically, the physician will suggest a treatment plan for the patient in the report.
 
"The three R's are important because this is what distinguishes a consult from an office visit," [...]