Otolaryngology Coding Alert

If you believe that Medicare allows billing only one ED visit per day, you may be incorrectly reporting 99241-99245 for your otolaryngologist's services instead of 99281-99285.

When an ED physician requests your otolaryngologist's services in the ED, you may assume that you should report a consultation (99241-99245, Office consultation for a new or established patient ) rather than an ED visit (99281-99285, Emergency department visit for the E/M of a patient ). Many ENT coders think only emergency department (ED) physicians may use ED service codes. "ED codes are not limited to the doctors employed by the ED," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "To use 99281-99285, the physician must perform the service in the ED." The type of doctor does not matter.

In fact, even if an ED physician who requests another doctor's services assigns 99281-99285, the Medicare Carriers Manual (MCM) section 15507 instructs primary-care physicians and specialists also to report an ED visit, unless the doctor:

  meets the criteria for a consultation
  delivers critical care services (99291-99292, Critical care, E/M of the critically ill or critically injured patient ) upon arriving at the ED
  admits the patient to the hospital (99221-99223, Initial hospital care, for the E/M of a patient ; 99218-99220, Initial observation care, per day, for the E/M of a patient ; 99234-99236, Observation or inpatient hospital care, for the E/M of a patient including admission and discharge on the same date ...).

If the otolaryngologist provides any of these three services, you should report the respective E/M service code instead of the ED visit. Knowing whether your ENT admits the patient is obvious. Knowing whether the visit meets the first consultation requirement request for an opinion may prove more elusive.

To meet these criteria, the ED physician must request the otolaryngologist's opinion on a patient, rather than transfer the patient's total care to the specialist. Therefore, you must determine which service your otolaryngologist performs for the ED physician to determine whether to report 99241-99245 or 99281-99285.
Transfer of Care Requires ED/Hospital Code

The key factor in whether you should code the visit as a consultation or as an ED visit is the intent behind the ED physician's request to the otolaryngologist. "Is the ED physician asking for an opinion?" asks Jean Ryan-Niemackl, LPN, CPC, an application support specialist for QuadraMed in Fargo, N.D. "Or is the ED physician asking the otolaryngologist to take over care of the patient?"

The MCM section 15506 B disallows consultations when the ED physician transfers complete patient care to the specialist. "Payment [for an initial consultation] may be made regardless of treatment initiation unless a [...]