Otolaryngology Coding Alert

Experts reveal 99241-99255's who, what and where requirements You can get the added revenue a consultation generates without raising a red flag, as long as your ENT's documentation shows that a proper source requested his opinion and he notes that he's sending a report of his findings to the requesting party.

With consultations making the Office of the Inspector General's 2004 Work Plan, inappropriately coding consultation services could mean you'll risk federal audits and requests for paybacks. To improve your reimbursement without triggering the OIG's scrutiny, coding experts answer these three questions on reporting consultations. 1. Who Qualifies as a Requesting Source?
 
For private payers, you may report a consultation when an independent speech therapist or a school nurse requests your otolaryngologist's opinion. Medicare, however, does not consider these individuals valid sources, says Betsy Nicoletti, CPC, a consultant with Helms & Company, a physician practice management company in Concord, N.H. Medicare specifically states that only a physician, a nurse practitioner, a physician assistant or a certified nurse midwife may request a consultation, she says.
 
CPT, on the other hand, also allows "another appropriate source," such as physical therapists, occupational therapists, speech therapists, psychologists, social workers and even lawyers to request an opinion. You may assume that third-party payers will use CPT rules unless they inform you otherwise, Nicoletti says.
 
For instance, suppose a school nurse notices that a child frequently slurs his speech. She notes her concerns and requests an otolaryngologist's opinion on the boy's speech impediment. Because the child has private insurance coverage, you may code a consultation (99241-99245, Office consultation for a new or established patient ...) for the otolaryngologist's services if she documents the nurse's request and issues a report of her findings to the school nurse. 2. What Consult Criteria Does Medicare Require? For a service to qualify as a consultation, the visit must fulfill the three R's - request, review and report, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions in Lakewood, N.J. In a nutshell, documentation must show that there is a request for an opinion, a rendered opinion, and a report sent back to the requesting physician, according to the Medicare Carriers Manual.

Make sure that a payer-recognized source requests your otolaryngologist's opinion. If no valid request exists, you should report a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) as long as your practice hasn't seen the patient in the last three years, Cobuzzi says. For patients your otolaryngologist has seen during that time, use an established patient office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established [...]