Editor's note: This is a transcript of an AudiologyOnline live expert seminar, and part of the Biling, Coding and Reimbursement online Boot Camp. View other courses in the series by visiting www.audiologyonline.com/bootcamp. It is recommended to download and review supplemental course materials, prior to reading this text course.
Today our course is on evaluation and management code use, or E/M codes, in audiology. What are these codes? These are the codes that physicians and non-physician practitioners use. A non-physician practitioner is not an audiologist; it is someone with more limited-licensure status, like a nurse practitioner or a physician’s assistant. It is a different level of care that has been put forth in the healthcare community to serve underserved areas. We are not deemed non-physician practitioners, and I want to make that very clear.
E/M codes are for physicians and non-physician practitioners to bill for office visits. Because those practitioners are different from us, we have procedures we can bill for to account for the time we are spending with a patient. Those other practitioners typically do not. As a result, there is a coding family called Evaluation/Management codes that are specifically for the visit between the physician and the patient that does not involve a procedure in any way, shape or form.
The current procedural terminology (CPT) manual is a definitive source on the use of coding. These codes can be used by health professionals with appropriate licensure and certification who perform services within their own scope of practice. That is an important feature for an audiologist using E/M codes. Is their use allowed within the scope of your audiology licensure law or within the scope of any contractual guidance that you have between you and your third-party payer?
Please note that most E/M code descriptions, except for the code 99211, contain the term physician. As a result, the use of E/M codes by audiologists is associated with some level of risk. As we know in coding, you always want the code to support the time or service provided. If the code has the term physician in it, and we are not physicians or non-physician practitioners, there is some risk in our utilization of these codes in healthcare. To be clear, I am not saying that you cannot use them. I am saying that you first need to investigate your licensure law and the guidance of any third-party payer agreement that you have signed to see if they allow for their use by an audiologist.
Common codes to be considered by the audiologist in the E/M code system are 99201 through 99203 and 99211 through 99213. We are going to talk about these codes a little later on in the presentation. You want to avoid 99204, 99205, 99214 and 99215 as they are inappropriate for audiologists to utilize. I will tell you that there are many otolaryngologists who would say that they are in appropriate for otolaryngologists to utilize because the level of the code requires a high risk of morbidity and mortality in the patient, such as that for bacterial meningitis. That being said, you should never utilize 99204, 99205, 99214, or 99215 in an audiology practice. That would be completely inappropriate.
The Do’s of Evaluation/Management Coding
As I said before, consult your payer contracts and fee schedules to determine if they allow for the use of E/M codes by audiologists. If you are in the process of negotiating a contract and you are not sure of the answer to that question, please send an e-mail or a letter to your provider services representative so that you can determine if this is something that is allowed within the contract. If you do not know, do not just assume that it is. You should always ask. You should consult counsel if you really are having difficulties determining that answer. If the companies do not allow you to utilize them per the specifics of your contractual agreement, then do not use them. That is a very important thing to remember.
Second, you need to confirm that your state licensure laws allow for E/M services and for the skills that are contained in them. For example, does your licensure law allow for you to do extensive case histories in medical decision making, which are part of the code? If your licensure laws do not allow you to provide that service or bill either a payer or a patient for that service, you would be in violation of your licensure laws. So it is very important that you do some investigation before you proceed. As always, if in doubt, consult the payer, consult the licensure board, and/or consult counsel before proceeding.
If you bill one payer for E/M codes, you must bill all of them, including for patients when it is not covered by the payer. Let me give you an example. Many third-party payers do allow audiologists to utilize and bill E/M codes for their patients. We know that Medicare does not recognize audiologists as a provider of E/M code services. So you cannot bill the third-party payer for the E/M service and not bill the Medicare recipient privately for the E/M service. You cannot bill one payer for something, no matter what the service is, that you are giving to other people for free. That would violate most managed-care contracts. Why would a managed-care entity allow you contractually to bill them for something that you are giving to everyone else for free? If a third-party payer allows you to bill them and collect payment, I would have Medicare beneficiaries sign an advanced beneficiary notice (ABN) as a voluntary notification. It is a voluntary notification because evaluation management services are statutorily excluded for coverage by Medicare because we are audiologists. But you would need to bill that Medicare recipient privately for the E/M service for which you are collecting payment from other payers.
You also need to do the documentation required of the E/M codes. If you are unwilling to take the time to do an extensive case history, document the results and also to do an extensive report and/or SOAP notes, you really should not utilize E/M codes. There is a course in this series specifically on documentation that will discuss the documentations requirement. If a payer ever questions the use of the codes, documentation is going to be very important, and you always need to meet the criteria of the code. That is the most important thing. You cannot bill a code for a time or service when you are not providing all the aspects of that item or service.
It is very important before you proceed that you educate yourselves on those documentation requirements and the requirements of utilizing E/M codes for every payer, not just Medicare. There is guidance from the CPT manual at the following link: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf. You can also read the E/M section of your CPT manual. Every office should have a CPT manual that is dated 2012 because there were coding changes in audiology related to otoacoustic emissions in the newest edition. In the front section of your CPT manual, preceding the E/M code section, is a section that will go over the appropriate use of E/M codes. The guidance in the CPT manual applies to every payer. However, the CPT manual is not Medicare guidance. It is guidance on the appropriate use of the code no matter who the payer is.
The Do Not’s of Evaluation/Management Coding
Do not ever utilize E/M codes for hearing aid visits. They have no role with a hearing aid patient. E/M codes should only be used for diagnostic test situations, not for hearing aid follow-up or management. You will never meet the requirements of a code using it on a hearing aid patient in any way, shape or form. If you want to have a code for a hearing aid follow-up visit, there is CPT code 92592 and 92593, hearing aid check monaural and hearing aid check binaural, respectively.
You also want to be very careful about using E/M codes if you work in an ear, nose and throat (ENT), medical or hospital setting. The reason is that you would run a very large risk, especially when billing third-party payers, because many audiologists are still, unfortunately, billing third-party payers other than Medicare under the provider number of the physician or the entity they work for, rather than utilizing their own provider number. As a result, you run a risk of double billing under the same facility or provider number and the same service on the same patient on the same date of service. I strongly caution against those in a medical, ENT, hospital setting utilizing E/M codes, no matter what the situation.
Basics of Evaluation Management Codes
The first and most important distinction is determining if this is a new patient or an established patient. How you determine whether the patient is new or established? They are deemed an established patient if they have seen you or another audiologist in your practice within the last three years. Otherwise, they would be deemed a new patient.
Next is outpatient versus inpatient status. This should not be a big issue, as I would never recommend an audiologist work in an inpatient setting utilizing E/M codes because it is a risk. Typically, you are going to be selecting the codes 99201 through 99215 for outpatient services. I should probably add here that while consultation codes exist in the CPT manual, they are non-covered codes by most payers. I would suggest that you defer to the E/M code family numbers that I am giving you and avoid the consultation code.
The third point is that the examination aspect of an E/M code is paid separately. When deciding what code to use in audiology, you need to completely ignore the time designate on the code. Time has no bearing on deciding which code to use in audiology. Those time distinctions for physicians are based upon the case history, examination and the medical decision making. In our case, we are paid separately for the examination or, in other words, the hearing test.
You want to focus on the level of case history and the level of medical decision making that you are providing rather than the time. That is how audiologists get in trouble by picking codes that are too high-level. They do not educate themselves first on the code use and end up upcoding. Upcoding is a false claim. If you are coding for something you did not actually provide based on time, you are upcoding, which is completely in appropriate in audiology.
Now let’s talk about the aspects of an E/M code. The first aspect is the type of history. Is it a problem-focused history, an expanded problem-focused history, a detailed history, or a comprehensive history? This can be determined by a few different things. What is the chief complaint? Typically, in our practice, the chief complaint is about the ear and/or the vestibular system. How extensive the chief complaint is determines how comprehensive the case history needs to be. That chief complaint will help guide how much you dig into what is going on with the patient. If the complaint is tinnitus or dizziness, you may delve more into the review of systems or past family or social history than if they are 75 years old and reporting merely a hearing loss.
There is also the history of the present illness. Is it acute or is it extended or chronic? That is an important distinction that needs to be made in the case history. Did you review any of the 14 body systems that were pertinent to the problem? Did you review every body system and ask the patient about their whole entire body health?
Finally, did you review past family or social history? Did you make it problem-pertinent or did you do a complete past family or social history to get a comprehensive history of the patient? These are called the review of systems. There are the constitutional symptoms of pain, diarrhea and fever that are about your overall constitution and are not necessarily related to a singular part of the body or system. Eyes are a body system. Ear, nose, mouth and throat is one pertinent body system for us. Honestly, it would be rare to review zero body systems, but if we just did problem-pertinent systems, ear, nose, mouth and throat would be the only body system that an audiologist would ask about.
I hope that we would ask about more systems, especially in the instance of a patient with complaints of dizziness, unsteadiness or unilateral symptoms-- a patient presenting with the warning signs of ear disease. Cardiovascular is another system that can have an impact on tinnitus and dizziness due to the vascular aspect. Eyes might be a body system you want to review if you are doing a vestibular workup as well.
Respiratory is a body system that, especially if you are doing a complete case history, would be a very extraneous problem-pertinent system. It does not always have a direct correlation to the auditory system. But if you were doing a complete review of systems, you could get information about the respiratory system if, for example, the patient had had lung cancer or emphysema. The drug regimen administered for such kinds of diseases can have ototoxic effects, and this is something you would want to gain information about.
Other body systems include gastrointestinal, which is the stomach and intestine, and genitourinary, which is the urinary and genital system. Both of these have rare implications for audiology. But again, people are reporting cancers or certain illnesses where the medications they were taking may have ototoxic effects. If you do not ask, you do not know.
The neurological system can have a direct effect on what we are testing for. That would be another problem-pertinent body system that we may want to review on a regular basis. Psychiatric history is important to review when you are dealing with tinnitus and dizziness. The endocrine system is your hormonal system; hematologic and lymphatic system relates to blood. Allergic and immunologic is another system that we want to always take into account. Many autoimmune diseases can have ototoxic effects, as can their medications. Gaining allergy information is important to make sure that the patient is not allergic to latex or rubbers or that you may be putting in or around their ear.
Let’s talk about the components of a family history. That is the health status or cause of death of your parents, siblings and children. This is important to know. Were your parents hearing impaired? At what age were they hearing impaired? Are your siblings hearing impaired? Are your children hearing impaired? Is there a family history of hearing loss or tinnitus? Some believe that Meniere’s disease has a genetic component to it. You want to delve into the family history of the patient. Immediate family-- parents, siblings and children- are most important.
Another thing is the specific disease history of parents, siblings and children. You want to know if they have had cancer or if they have had tumors removed. That could be important based on the symptoms that the patient is presenting with. Other pertinent information is hereditary medical conditions that have been reported or syndromes or conditions in the family history that could have an impact on the auditory system.
Past history that is unique to that patient is of obvious interest. For that particular patient, what are the prior diseases, illnesses, injuries or accidents? You want to know if they were in a car accident and had a head injury. You want to know if they have had a history of concussion. You want to know if they have multiple sclerosis, cancer or diabetes. A lot of common conditions have a very big impact on the auditory systems and on the symptoms the patient may be reporting. Have they ever had ear surgery before? Have they had scarlet fever, mumps or meningitis? These are important things to know that you may not find out if you do not ask.
The surgical history of the patient is also important to know. Have they had their tonsils removed? Have they had a history of tympanostomy tubes? Have they had a cholesteatoma removed? You may even want to know about surgeries that they have had on the rest of their body. Maybe they did not answer your questions about diseases, but they tell you they had a lung removed in your questioning about previous surgeries. If they do not answer one part of the case history completely, you are asking it again so you can get a little more information.
Ask about current medications or treatment. This is a very important part of any case history, even if you are not utilizing an E/M code, because so many medications can be ototoxic. This information helps you determine what tests are the best to perform and what your realm of decision making will be for the whole patient. In relationship to that, allergies can also have an impact on conductive hearing losses. Patients who report ear pain, fullness, pressure or drainage may have additional allergic issues. Maybe they are allergic to the earphone that they are putting in for their phone or their iPod. These are things that you might want to explore, especially if they have a latex allergy. There are some people that do glove up when they see patients. If you are gloving up, you need to know if that patient is allergic to latex. That is an important thing to ask your patient and document.
The social history is still a very important part of a case history and is included if you are going to use E/M codes. What is their marital status, including domestic partners? You want to know if they are married, divorced, gay or lesbian. Gay or lesbian affiliation can be important because you do not want to diminish the role of their domestic partner in their decision making. If someone comes to their appointment without their spouse or partner and you are going to talk about hearing aids, you can suggest that the spouse come to and be with the patient for that visit.
For employment or occupational history, you want to know if they served in the military, worked in a factory or were exposed to extraneous noise. What is their recreational history? Are they a hunter? Do they like to use heavy equipment and do a lot of things around their yard? Are they avid music fans? Do they go to a lot of concerts and listen to a lot of music? That information is important in audiology to know what can explain some of the hearing losses or symptoms that the patients are reporting. Also take a history of drug, alcohol and tobacco use. This can be important when you are doing vestibular testing or if the patient is reporting tinnitus. This can help us decide not only what tests need to be performed, but how we can interpret those tests.
Let’s get into how we determine on a case history what is problem focused versus expanded problem focused. Problem focused is when you are only asking about chief complaint and a brief history of the present illness or problem. You are not asking a lot of questions. Unfortunately, that is the level of case history I see in a lot of audiology practices today. They do not delve into the patient as a whole. They tend to focus on the ear and the presenting problem itself. The expanded problem-focused case history is where you talk about the chief complaint, you do a brief history of present illness or problem, and then you do a problem-pertinent system review. For example, if the patient is dizzy, you may only review the ears and the neurological system. You do not delve more into more of the body systems. It is a little more than you did before, but it is still not a full-scope, comprehensive case history that includes a review of all 14 body systems.
A detailed case history explores the chief complaint and provides an extended history of the presenting illness or problem, getting more into family history and occupational history. You are going to do a problem-pertinent systems review, expanded to include a limited number of additional appropriate systems. For example, you might ask about the cardiovascular system. You might ask more about the psychiatric system or the immunologic system. And then you include problem-pertinent family or social history. You are expanding the case history to learn more about the whole patient and how that can explain the symptoms and conditions they are reporting.
Lastly is the comprehensive case history. Again, you analyze the chief complaint, take an extended history of the present illness or problem, review all 14 body systems to find out about any illnesses, diseases or conditions that patient has related to that body system, and you do a complete family and/or social history. Ask extensive questions about all three.
Selecting the Appropriate E/M Code
So now we are going to get to another aspect of the how you select an E/M code, which if you recall, for audiologists, is the level of the case history you provide. Next, is the level of medical decision making or the recommendations and the integration of information that you provide. The options are: straight forward, low complexity, moderate complexity and high complexity. Some components relating to that that is the number of diagnoses or management options available: none, minimal, limited, multiple or extensive; the amount and complexity of data to be reviewed: none, minimal, limited, moderate or extensive. It would be difficult in audiology to review no data, by the way. Usually we are going to have minimal data at the very least. We are reviewing our own test results, so is it limited, moderate or extensive? You might classify it as moderate when you are doing vestibular testing or an assessment of tenderness. You may see extensive when we are talking about cochlear implant candidacy or implantable device candidacies where you are talking about very high-end evoked potentials. Extensive data review might also include central auditory processing evaluations, where you are reviewing a lot of records from the school. That is a more extensive amount of data and complexity to be reviewed.
Also included in the medical decision making is the risk of significant complications, morbidity, or mortality. Is that risk minimal, low, moderate or high? Typically, we are in the minimal to low area of the morbidity or mortality for audio-vestibular issues.
Let’s talk about these more specifically now as they relate to the code. For a new patient, to utilize 99201 (office or other outpatient visit for the evaluation and management of a new patient), you would need a problem-focused history, a problem-focused examination and straightforward medical decision making. Straightforward medical decision making is typically going to mean ant you have a minimal number of diagnostic and management options available. The amount of data to be reviewed is little to none, or perhaps in the minimal to limited area. The risk of morbidity and mortality is minimal. If that is what occurred in your case history and medical decision making, this would be the most appropriate code to select. Remember that the time you spent obtaining this information does not apply.
This code (99202) again, is for a new patient. You take an expanded problem-focused history and you have straightforward medical decision making. You have a case history where you have talked about the chief complaint and documented it, a brief history of the present illness or problem. To me, a brief history would probably be to just ask the questions of the eight warning signs of your disease from the Food and Drug Administration (FDA). Is there hearing loss in the right or left ears? Is it sudden? Is it fluctuating? Do you experience tenderness? And then you do the problem-pertinent system review.
A problem-pertinent system review in our case would be where you are really just asking questions about the ear, nose, mouth or throat. Then you have straightforward medical decision making. There are not a lot of diagnostic or management options for this code. The amount of complexity of data is minimal. You probably are reviewing your case history, an audiogram and tympanometry in this case. With 99201, you might not even be reviewing tympanometry because you did not do it because it was not necessary. But in the next case you might be reviewing tympanometry and otoacoustic reflexes. The risk of morbidity and mortality, again, is going to be in the minimal range.
When using the code 99203, you will take a detailed history. A detailed history is an extended history of the present illness or problem. That means you have to ask more questions. You are going to go beyond the eight warning signs of ear disease. You may talk more about how long the hearing loss has been present. You get into if the underlying symptoms such as fullness or pressure, pain or unsteadiness. You are going to delve more into the history if they have ever worn a hearing aid. An expanded problem-pertinent system review includes a limited number of additional appropriate systems. You have expanded beyond ear, nose, throat and mouth and are now looking into, perhaps, neurological, psychiatric or cardiovascular systems. The medical decision making under this code is now of low complexity. You have moved out of the minimal category into low complexity category. Because of the risk of significant complications, morbidity and mortality has increased. You also have more data to review. Maybe you are reviewing a vestibular test battery and auditory brainstem response (ABR) results. Maybe you are reviewing results that were sent over from a physician or another medical specialty. Now you are going to have a multiple number of diagnoses and management options available. In my opinion, 99203 is as high as an audiologist should go in terms of coding. Beyond that, the risk of morbidity and mortality rises into the moderate range, and I think that that is inappropriate, both for our general scope of practice and for the auditory and the vestibular conditions as well.
These codes correlate to the realm of established patients. This is a very important thing. Code 99211 (office or other outpatient visit for the evaluation of management of an established patient) does not require a physician to be present. That is a code that, within the code description, is allowed for use by an audiologist. This code does not have components of a case history. It does not have a requirement for components of medical decision making. It is not part of the code. It is a patient that is presenting to you with minimal issues. Again, that would be a very legitimate code to use for follow-up diagnostic testing. 99211 is the one code in all of the family of codes that you could defend as an audiologist with the code book, because, again, it does not say it requires the presence of a physician.
99212 follows similar guidance as 99202, but is for an established patient. So the question is, which one would you pick? If it were me, I would pick 99211 if this was an established patient and the only testing I performed was an audiogram, and the only questions I asked were about the eight warning signs of ear disease.
I would use 99212 when a patient has noticed a change in hearing and a very basic follow-up hearing test is required. If I was going to utilize 99202 for a new patient, I would utilize 99212 for an existing patient if I had gotten to that level of case history and medical decision making.
99213 requires an expanded problem-focused history and medical decision making of low complexity.
I want to stress something from the beginning of the presentation again. I am not telling you not to use E/M codes in the audiology world. I am telling you that before you utilize them, you need to educate yourself. The first step, as far as I am concerned, is reading the E/M section of the CPT manual. No one should utilize E/M coding until they have personally read that section and read the descriptions of the codes. A CPT manual costs approximately $80.00. You do want the most recent one because things are always changing. In this manual, there is a decision tree. It will talk about all the case histories and what are consisted in each. It has a table of the complexity of the medical decision making and how you decide which category to select. There is a lot of wonderful information. Again, if you read the description of the code it has the term physician within the code, except for 99211, you want to educate yourself first.
The link that I provided earlier is an excellent resource. It is a wonderful document that you can access to have E/M coding completely spelled out for you. That is the first step before proceeding. And if you are already doing E/M coding, I strongly recommend you go back to this step and educate yourself, because you are going to see that there are documentation requirements, and you need to make sure that you are meeting them if you are audited.
It would not be hard to get audited. What I would suspect would happen, and what I have seen happen, is that a patient complains about the charge. Usually the complaint is that they were charged for this time or service. When they start to investigate they determine that it may not have been an appropriate charge. That is why you want to know what you are doing before you do it. The issues of E/M codes are oftentimes driven by patient complaints.
Second, before you do it, you need to confirm what your state licensure laws allow. If your state licensure law does not allow medical decision making by an audiologist, the utilization of these codes would be inappropriate, and you would then be practicing outside of your scope of practice.
Last, but certainly not least, is a very important aspect that you need to take into account, and that is, “What do your third-party payers allow?” If they do not allow you to use the E/M codes, you need to know that. If they do allow you to use them but they do not cover those codes, then you need to put the processes in place of charging your patients privately. In some cases, that may require notifying the patients in writing. This is not unique to Medicare. Many third-party contracts, when you read them, tell you that patients need to be notified in writing of non-covered services. You need to know what those notification requirements are. You need to know how to document those cases and what the patient needs to be provided. You need to put processes and procedures in place to make sure that you are doing this in compliance, which includes meeting all the documentation requirements and earning the money that you are billing for. Otherwise, you are creating a false claim.
For example, 99205 is office or other outpatient visit for the evaluation and management of a new patient which requires a comprehensive case history, a comprehensive exam and medical decision making of high complexity. High-complexity medical decision making means the risk of morbidity or mortality are high. This code asserts that the number of diagnostic and management options is extensive, and the amount of complexity of data to be reviewed is extensive. If you are utilizing that code right now, you have created a false claim because you were upcoding. It is very, very important that you make educated decisions based upon what your knowledge base is, not what your colleagues and other people are doing.
Never use these codes with hearing aid patients because they have no role with a hearing aid patient. My advice is to proceed with extreme caution if you work in a medical center and you are utilizing these codes.