Otolaryngology Coding Alert

Coding an E/M service with a minor procedure never ceases to stump even the most confident coding experts, so follow four tips to report these services without losing ethical reimbursement and committing fraud. Report Significant, Separately Identifiable E/M When an otolaryngologist provides a separate and significant E/M service and a minor procedure during the same visit, you should bill both services and append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service. Modifier -25 indicates that the E/M is separate from and significant to any minor procedure that the physician also provides on the day of the visit, says Shirley Fullerton, CPC, supervisor of HIM (Medical Records) for the Valley Hospital Medical Center in Las Vegas. "The key words are 'separate and significant,' " she says. Some insurance companies interpret "significant and separate" to mean that you must treat something different, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "CPT states that this is not necessary, and Medicare does not require a different diagnosis." For instance, an emergency-room physician requests an otolaryngologist's opinion on whether a patient who has respiratory distress needs an emergency tracheostomy. The otolaryngologist performs a history, examination and medical decision-making and agrees that the patient requires a trach. You should report the tracheostomy (31603, Tracheostomy, emergency procedure; transtracheal) and the E/M (99241-99245, Office consultation for a new or established patient) appended with modifier -25. Although only one diagnosis, respiratory distress (518.82, Other pulmonary insufficiency, not elsewhere classified), exists, the E/M is allowable because the physician performed a separate service to determine the procedure's necessity.

Because CPT doesn't require a second diagnosis, many practices want to charge an E/M attached with modifier -25 in addition to cerumen removal (69210, Removal impacted cerumen [separate procedure], one or both ears) with an impacted cerumen diagnosis (380.4) only. "Cerumen removal doesn't pay well," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryn-gology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. When cerumen removal can take 30 minutes or more on both ears, physicians feel that they're not paid adequately. Charging an E/M in addition to the removal, they reason, helps them obtain "entitled" reimbursement. You should not bill cerumen-removal-only visits this way, Cobuzzi says. For instance, a patient comes in complaining that he can't hear well. The otolaryngologist looks in his ear, sees impacted cerumen and removes it, and this is all that is done and all that is documented. In this case, bill the cerumen removal (69210) only, she says: "The physician performed nothing else." You [...]