Otolaryngology Coding Alert

You should code a consultation if the otolaryngologist:

provides the requesting physician with a written report notes that medical advice was requested and provided did not assume primary care of the patient. "As long as the documentation includes a written request for a consultation and the otolaryngologist's written report to the primary care physician (PCP), the otolaryngologist can bill the appropriate consultation code," says Randa Blackwell, coding and reimbursement specialist with the department of otolaryngology at the University of Maryland in Baltimore. If the otolaryngologist performs a procedure after seeing a patient at the request of another physician, the visit may still be a consultation if:
the decision to perform the procedure was made during the visit, not beforehand
modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier -57 (Decision for surgery) is appended. If the surgery has a 90-day global period, use modifier -57. Otherwise, use modifier -25. Note: Some carriers may not follow these recommendations and may request different (or no) modifiers. Three series of consultation codes exist: 99241-99245 Office or other outpatient consultations 99251-99255 Inpatient consultations 99261-99263 Follow-up inpatient consultations. Outpatient Consultations Scenario 1: Suspecting hearing loss, a family physician orders a screening audiogram for a 72-year-old patient. The PCP sends the patient to an otolaryngologist for more tests. The otolaryngologist examines the patient and performs additional tests to define the cause of the hearing loss. Because treatment was uncertain when the patient visited the otolaryngologist, you should code an outpatient consultation (99241-99245) if the requesting physician requested the otolaryngologist's opinion in writing, the request is noted in the patient's medical record, and the otolaryngologist provides the PCP with a written report. The testing should be billed separately (probably 92557, Comprehensive audiometry threshold evaluation and speech recognition [92553 and 92556 combined]). Inpatient Consultations Scenario 2: A patient with respiratory problems related to a cardiovascular incident is admitted to the hospital by his attending PCP. The internist is unsure if the patient requires a trach, so an otolaryngologist is called in. The otolaryngologist determines that the trach is not necessary at this time because the patient is ventilating well and has satisfactory oxygen levels.

Even though the patient has already been diagnosed, the PCP wants the otolaryngologist's opinion on how best to treat the patient. Therefore, the otolaryngologist may bill the appropriate-level initial inpatient consultation code if there is a written request in the patient's chart for the otolaryngologist to see the patient.

A separate report is not required in the hospital setting, according to section 15506 of the Medicare Carriers Manual (MCM), which states: "The request for consult [...]