Scientific and technical advancements have allowed otolaryngologists to do more and more procedures in their offices, rather than in the operating room at the hospital. But this change, as great as it is, has led to other problems related to coding and reimbursement, said Dr. Rosen. How do we pay for the required staff, technology and equipment? When we worked primarily in a hospital setting, many of these things were provided and paid for us.
Explore This IssueAugust 2007
For example, vocal fold [VF] injection materials are expensive, said Dr. Rosen. Since we are now doing injections in the office setting, we are responsible for paying the costs up front and hoping that the insurance company covers it. When my office tried to bill CPT code C1878 [material for VF medialization, synthetic], it was constantly denied. We finally discovered that the code was designated for hospital use only, so we are in the process of trying to have the ruling changed to include outpatient use.
There is no doubt in my mind that these changes improve the quality of care we give our patients and help to lower the insurance carriers’ costs, said Dr. Rosen. However, until certain coding and reimbursement issues are resolved, I don’t see that we, as otolaryngologists, are benefiting.
A common mistake in coding is selecting the wrong E&M level of service, said Dr. Setzen. The complexity of the medical problem, including history and exam and medical decision making, dictates the level of E&M service.
Most physicians already have in mind what needs to be done when a level II new patient walks through the door, as this individual usually has a very straightforward, easy problem, elaborated Ms. Cobuzzi. A level III new or established patient is a little more complicated and requires an expanded problem-focused exam that involves two to four organ systems.
CPT code 99214, or level IV, is defined as an established patient visit involving a detailed history, a detailed examination that involves five to seven organ systems, and MDM of moderate complexity. Level V established patients require a comprehensive history and exam and a very high degree of complex MDM (see www.aafp.org/fpm/20031000/estabpatientvisits.pdf ).
Surprisingly, physicians tend to downcode themselves on established patients, even though they only require two out of three key components, as long as medical necessity justifies the care, but upcode themselves on new patients, which are harder to document because they require three out of three components, said Ms. Cobuzzi. Whether it’s due to fear of violating fraud and abuse laws or confusion regarding E&M documentation guidelines, physicians can lose significant revenue as a result of downcoding.