SAN DIEGO-In order to remain compliant, as well as to receive fair and appropriate reimbursement, you must code and document correctly, said Michael Setzen, MD, Clinical Associate Professor of Otolaryngology at NYU School of Medicine and Senior Clinical Attending in Otolaryngology at North Shore University Hospital in New York, when he moderated the panel discussion, How the Experts Code and Document Laryngology and Esophagology in the Office and the OR, at the April 2007 Combined Otolaryngology Spring Meeting.
Explore This IssueAugust 2007
Furthermore, you must show medical necessity and use correct CPT codes that match the congruous ICD-9 codes, continued Dr. Setzen. Otolaryngologists need to understand that proper coding is not only necessary for reimbursement, but that it will also assist them in the validity of their claim, should they ever be audited.
As he showed a slide of a jail cell versus a stack of money, panelist Clark Rosen, MD, Director of the University of Pittsburgh Voice Center and Associate Professor of Otolaryngology at the University of Pittsburgh School of Medicine, stated, This image is what should guide you, not paying off your car or overhead. You must code in an ethical and appropriate fashion to avoid having someone come and knock on your door asking for a payback.
Which is exactly what happened to some otolaryngologists who incorrectly billed E&M services-that is, evaluation and management-using a -25 modifier with laryngoscopies, said panelist Barbara Cobuzzi, MBA, Director of Outreach Programs for the American Academy of Professional Coders. Those who didn’t have the supporting documentation which showed that the E&M service was a ‘significant and separately identifiable’ service from the laryngoscopy [the definition of the -25 modifier] to dispute the refund request had to send in refunds.
The key with the -25 modifier is that any minor procedure, such as a laryngoscopy, includes minor history exam and medical decision making [MDM] in the procedure already, continued Ms. Cobuzzi. You have to make sure that the documentation shows that the E&M was beyond the included minor E&M service. The E&M service must be medically necessary, as well as significantly and separately identifiable from the laryngoscopy procedure. It can’t be part of your otolaryngology exam; you can’t double-dip. (See sidebar.)
However, if you decide to do the laryngoscopy because of inadequate visualization and you document this problem in your chart, then you can take credit for it in the exam, as well as for the procedure, explained Ms. Cobuzzi.
Advancements in Otolaryngology Affect Coding
We’ve seen significant advancements in three areas of otolaryngology: (1) surgical precision, like microflap surgery and Gray’s mini-thyrotomy, (2) technology development, including new augmentation materials and fiber-based lasers, and (3) site of service, which has changed from the OR to office-based procedures, said Dr. Rosen. These changes are great for us and our patients, but they are really difficult from a coding perspective because we are way ahead of the coding curve.
It’s very hard to code for a new surgical procedure if it doesn’t have a code, and some of our current codes are based on very antiquated techniques, continued Dr. Rosen. Therefore, about six years ago, Mark Courey, MD, who is the Director of Laryngology at the University of California, San Francisco Voice Center, and myself, in conjunction with the Committee on Speech, Voice and Swallowing Disorders of the American Academy of Otolaryngology-Head and Neck Surgery, started the very long, laborious process of getting new microlaryngeal codes. Some of our colleagues will argue that they were getting better pay when they used unlisted codes, but I think as a whole, we are better off having new and specific codes.
For example, I suspect many ENTs are now using microflap CPT codes 31545 and 31546, instead of 31541, as the codes are very straightforward and allow them to bill bilateral, which was not possible before, said Dr. Rosen. (31545, WRVU 6.3 and 31546, WRVU 9.73 are for laryngoscopy direct, operative with microscope or telescope with submucosal removal of non-neoplastic lesion(s) of VF, reconstruction with local tissue OR grafts, includes obtaining autograft.)
Coding always lags behind both new technology and new procedures, said Dr. Setzen. When we use a new technology or procedure in otolaryngology that doesn’t have a specific code, we have to negotiate with the American Medical Association and other specialty societies to create a new code that is fiscally neutral-that is, money must be taken from one source and allocated to another to allow for reimbursement.
In the event that there is no specific CPT code, then an unlisted CPT code must be used, continued Dr. Setzen. The only problem with an unlisted code is that the insurance companies often don’t understand it, pay you minimally, and demand a tremendous amount of paperwork to back it up. It’s nicer to have a definite code with a value to it, rather than use an unlisted code.
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.
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.
Otolaryngologists can also bill a 99214 based on time, not on the history and physical exam and MDM, if they spend at least 25 minutes with a patient and more than 50% of their time involves counseling or coordination of the patient’s care. Documentation must include the total time spent for the encounter and the amount of time spent discussing the patient’s care, as well as what was discussed.
Knowing how to code E&M appropriately will be critical to ensuring that you receive the reimbursements you are entitled to, especially should Medicare decide to decrease reimbursements, said Dr. Setzen.
Understanding what constitutes a consult is also important, added Ms. Cobuzzi. Although there have traditionally been just ‘three Rs’ that we talk about regarding a consult-‘request,’ ‘render,’ and ‘respond’-I’ve added two more: ‘reason’ and ‘return.’
In January 2006, the Centers for Medicare and Medicaid Services changed the rules indicating that there had to be a reason for doing a consultation, continued Ms. Cobuzzi. This simply means that you need to include the reason why the patient was referred to you as part of the request. Be sure to write this in your chart and send some type of response letter to the requesting physician for his or her chart that also indicates that you are proceeding with treatment unless you hear otherwise.
I think of the ‘return’ part of the consultation like Netflix-you borrow the DVD, view it, send it back, but do not buy it. Similarly, once you’ve rendered care to the patient, you need to return the patient ‘on loan’ to the requesting physician and by doing so, you are showing that that episode of care is finished and you are now ready to move on.
Coding in otolaryngology will continue to evolve as newer technologies and procedures emerge. Meanwhile, there are sometimes no easy answers as to what are the correct CPT codes to use, summarized Dr. Rosen. To negotiate for fast, clean preapproval and payment, meet with the insurance provider(s), present the facts, and demonstrate the cost savings. Or write a cover letter explaining these items and attach it with your claim submission.
Otolaryngology Exam (’97)
- Examination of oropharynx: oral mucosa, hard and soft palates, tongue, tonsils and posterior pharynx (e.g., asymmetry, lesions, hydration of mucosal surfaces)
- Inspection of pharyngeal walls and pyriform sinuses (e.g., pooling of saliva, asymmetry, lesions)
- Examination by mirror of larynx including the condition of the epiglottis, false vocal cords, true vocal cords, and mobility of larynx (use of mirror not required in children)
- Examination by mirror of nasopharynx including appearance of the mucosa, adenoids, posterior choanae, and eustachian tubes (use of mirror not required in children)
For More Information
American Academy of Professional Coders www.aapc.com
ENT Coding Today www.entcodingtoday.com
American Academy of Otolaryngology-Head and Neck Surgery Coding and Reimbursement Resources www.entlink.net/practice/resources
©2007 The Triological Society