Otolaryngology Coding Alert

Returning a patient puts you on the 9924x path When you-re coding new patient office visits and consultations, you-re stuck between a rock and a hard place. If you bill all new patient encounters as higher-paying consultations (99241-99245, Office consultation for a new or established patient -), you-re sending up a red flag for payers. But if you err too conservatively to lower-paying office visits (99201-99215, Office or other outpatient visit ...), you-ll sacrifice payment. Here are some clever ways to differentiate a consult from an office visit. Check for Strategy Versus Out of Loop Ask, "Why is the physician sending us this patient?" If the physician requests your ENT's opinion regarding a patient's treatment and/or plan, the service is on its way to qualifying as a consultation. On the other hand, you should use an office visit code for a referral. Example: A pediatrician sends a patient with chronic tonsillitis (474.00) to your ENT and requests his opinion on continuing conservative antibiotic treatment rather than surgical tonsillectomy. Because the pediatrician asks for your physician's opinion and expects a treatment strategy report, the encounter could qualify as a consultation (99241-99245) -- if the service meets the remaining consultation requirements. But suppose the patient has 3+ tonsils that are interfering with breathing. The pediatrician sends the patient to your office expecting that an ENT will admit the patient to the hospital for an immediate tonsillectomy (such as 42825, Tonsillectomy, primary or secondary; younger than age 12). In this case, the originating physician is out of the care loop -- and you should code an office visit (99201-99215) for the initial ENT-patient meeting. Host a Happy Hour Your ENTs may comply with documenting an office consultation's reason and request in the patient's chart. But how do you get sending offices to comply with this possible audit item? "Have staff over for a cocktail hour, and show them the value of distinguishing a referral (transfer of care) from a consultation (a request for opinion)," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. The educational training will more than pay for itself. Encourage attendees to always use the term "request" when asking for a physician opinion and reserve "referral" for a transfer of care. The term "referral" presumes that the accepting physician will assume total care, disqualifying the visit as a consultation, according to Medicare guidelines. Fax a Form Alternatively, when an office sends you a patient without indicating the physician's intent, fax them a consultation confirmation form (for a sample template, see "Stop Trying to Read the Requesting Physician's Mind -- Use This Confirmation Sheet Instead" [...]