Otolaryngology Coding Alert

Question: A patient's father came in to review test results without the child present. Should the otolaryngologist charge an E/M service? Is a patient exam a requirement of an E/M service?

Ohio Subscriber

Answer: When counseling and/or coordination of care dominates a visit, you may use time as the controlling factor in selecting an E/M code, according to CPT E/M Services Guidelines. Time-based coding trumps all typical E/M components of history, examination and medical decision-making. So your otolaryngologist may report an E/M service, such as an office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...), without performing an exam.

Problem: Medicare requires a patient to be present to bill an E/M service. For visits without the patient present, you should charge the service to the family member or treat it as a courtesy. Private payers may not require patient presence. Find out from the particular payer in writing if they follow Medicare guidelines or if they follow the AMA CPT guidelines, which indicate "patient and/or family."