Otolaryngology Coding Alert

Medicare is focusing on these 5 areas You should pull sample charts to make sure your otolaryngology coding will stand up to increased government scrutiny.
 
The Office of Inspector General (OIG) released its 2004 Work Plan on Oct. 1. The 90-page report, available at www.oig.hhs.gov/publications/workplan.html#1, sets forth the agency's planned projects, which include examining claims for specific problem areas. To avoid triggering an audit, coding experts offer advice on protecting your practice from these five target areas:

1. Consultations: As usual, the OIG will focus on proper documentation for 99241-99255 (Office consultation for a new or established patient ...). Make sure your consultation documentation shows a request, review and report.

2. E/M services: Medicare will examine physicians who have higher-level E/M services (99204-99205, Office or other outpatient visit for the evaluation and management of a new patient ...; 99214-99215, Office or other outpatient visit for the evaluation and management of an established patient ...; and 99244-99245, Office consultation for a new or established patient ...) outside the bell curve. Run an E/M service report and compare your results to state and national ENT averages, says Teresa Thompson, CPC, CCC, a nationally recognized speaker on otolaryngology coding, compliance and reimbursement and president of TM Consulting in Carlsburg, Wash.

3. Modifier -25: The OIG will determine whether claims containing modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) represent a significant, separately identifiable E/M service. Pull some modifier -25 charts and make sure your otolaryngologist's documentation supports the situation, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "Verify that the office visit is both separately identifiable from the procedure's typical work and that the level of work is significant," she says.

4. Modifier -59: Be prepared for the OIG to target your modifier -59 (Distinct procedural service) claims. Medicare will review claims in which physicians used modifier -59 to override the National Correct Coding Initiative edits. Check that the service meets modifier -59's definition as a separate site, lesion, incision/excision, etc. Also, make sure the edit allows a modifier to break the bundle.

5. Incident-to: Medicare will look at incident-to claims to ensure that your otolaryngologist provided direct supervision during these services. Pull some sample allergy-shot charts to make sure you're billing these services under the supervising physician.