by Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
April 19th, 2021
Question: I am in an ENT office as part of a large clinic with separate practices including audiology, CT, and allergy, all billing under the same TAX ID. Sometimes tests are ordered which are done in other departments that my office does not bill for, would those be considered an outside source?
Answer: This is a great question and one that has been asked by many coders and auditors. To answer it, we begin by looking at the following CPT definition for “External physician or other qualified healthcare professional” as noted in the AMA's Errata and Technical Corrections - CPT 2021 (emphasis added):
“An external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or subspecialty. This includes licensed professionals who are practicing independently. The individual may also be a facility or organizational provider such as from a hospital, nursing facility, or home health care agency.”
If you are in a group practice and the physician/QHP who ordered the test is of the same specialty and subspecialty as your physician, then the answer to the question is NO, they would not be considered an outside source (external physician/QHP). However, if you are in a group practice and the physician/QHP who ordered the test is NOT of the same specialty or subspecialty, then the answer is YES, they are considered an outside source.
Another great example of simplifying this E/M guideline, and one that so many of us have been doing well for so long, is how we determine when a patient is considered new or established to a group practice. According to the CPT codebook:
“A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”
If Dr. Jones (ENT) and Dr. Smith (family medicine) are in the same group practice and Dr. Smith refers one of her established patients to Dr. Jones for chronic ear infections, Dr. Jones would be able to charge a new patient encounter for the service because they are not of the same specialty nor are they of the same subspecialty.
The same is true for determining what tests can and cannot be scored as part of the E/M MDM data element. Here are a few examples:
Scenario: Dr. Jones (ENT) performs an E/M service on little Jimmy, a 2-year-old boy who presents with his parents today for evaluation of his ears, hearing, and developmental delay. His parents are with him and provide a comprehensive history for the provider. After examination, Dr. Jones feels it necessary to have the patient obtain an audiogram to determine possible conductive hearing loss and contacts John Paul Reiner, AuD (same building, same group practice) to see if he can squeeze little Jimmy in for an audiogram today. Dr. Reiner (different specialty) performs the audiogram, documents his professional interpretation into a report and sends the results, report, and little Jimmy back to Dr. Jones for the results.
Dr. Jones reviews the audiogram results and Dr. Reiner’s report and determines little Jimmy needs a CT to determine if there are any bony abnormalities within the ossicles that may be the cause of the conductive hearing loss, as there is no infection or fluid present in the inner ears. The results, assessment, and treatment plan are discussed with the patient’s parents, a CT scan is ordered, and a follow-up encounter scheduled in two weeks to go over the results and determine a plan of action for treating the conductive hearing loss.
Dr. Jones can count three things in the MDM data element section:
- Assessment requiring an Independent historian. The patient is 2-years old and cannot provide an adequate medical history so the parents provided that information to Dr. Jones.
- Ordered and reviewed a test (audiogram). Remember that when you order a test and review the results on the same day, it is only scored once as part of the E/M encounter for that day. However, if you performed the professional component of the test then you cannot count it at all.
- Ordered a test (CT scan). This is to be performed on a different day by the imaging center which you stated was billed separately as a different specialty/subspecialty for the professional and technical component of that test. When the patient returns for follow-up which includes the results of the CT, Dr. Jones will be able to count the review of a test (CT scan) as a single MDM data element from a single unique source.
NOTE: If Dr. Jones had an ENT practice where he employed a certified audiology technician to perform audiograms (technical portion) and then Dr. Jones interprets them, documents the findings in the E/M encounter note or a separate audiology report (professional interpretation), then Dr. Jones could NOT count order/review audiogram (test) in the MDM data element portion of the E/M service.