Pulmonology Coding Alert

Some coders face a quandary when their pulmonologists get involved in a surgical case, but these operative consult rules and this often-overlooked opportunity can help.

When your pulmonologist is asked to consult on another doctor's patient in the office before surgery, you will typically report both an outpatient consultation code (99241-99245) with the diagnosis code for a pre-op respiratory exam (V72.82), says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist with the University of Pennsylvania Department of Medicine in Philadelphia. Make sure to document the patient's underlying condition, such as chronic obstructive pulmonary disease (COPD, 490-496) or asthma (493.xx), since such conditions put them at a higher risk for surgery and justify the need for perioperative risk assessment, Pohlig adds.

Don't miss this: Many offices forget to take advantage of one consult coding opportunity: consultation on an existing patient. If one of your regular patients is about to undergo surgery, and the surgeon requests a pre-op risk assessment for a new issue report the service with a consult code, Pohlig points out.

However, there is another scenario when coders report consults when they shouldn't. If your pulmonologist performed a consultation service for a patient's pre-op care the doctor cannot bill for post-op services with a consult code, explains Pohlig.

Why? Once the pulmonologist has participated in the patient's pre-op care, the pulmonologist's post-op role is now one of co-management rather than simply providing opinion or advice, Pohlig says. However, you can bill for post-op services (following a pre-op consult) with the subsequent care codes (99231-99233).

To differentiate between a consultation and co-management service following surgery, consider these examples:

Consultation: A patient who is post-cabbage (having undergone a coronary artery bypass graft [CABG]) is experiencing difficulty with lung expansion and breathing and is developing pleural effusions. Provided that your practice did not evaluate the patient preoperatively, your pulmonologist's participation would qualify as a consult if the requesting physician asked the pulmonologist to help determine management options, such as whether to treat the patient with medication or perform a thoracentesis, Pohlig says.

Co-management: Conversely, if a post-op cabbage patient suffers from recurrent pleural effusions, the surgeon may request that the pulmonologist perform a thoracentesis. If the pulmonologist provided pre-op evaluation or if the surgeon gave no indication that she was seeking advice rather than requesting a procedure, this would qualify as co-management, notes Pohlig.

The most common reason for office consultation claim denial is incomplete documentation. Cover your consultation P's and Q's with these best practices in documentation.

To report an outpatient consultation code (99241- 99245), says Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, make sure you have in the patient file the critical pieces Medicare wants to see:

• reason for consultation

• request for opinion

• render of opinion

• report back of findings.

Litmus test: To meet consultation criteria, the requesting physician must loan the patient to the consulting pulmonologist for a specific problem and ask for an opinion. Whether or not your pulmonologist ultimately ends up treating the patient, you can still bill the initial visit as a consultation if its intended purpose is to provide the requesting physician with a specialist's advice on diagnosis or management.

Medicare auditors want to verify that there is a request for an opinion versus a transfer of care between physicians. "The best way to back up the request for a consult is to have something in writing in your patient's chart indicating that a physician has requested your opinion, and the problem the physician has requested your opinion on," says Teresa Thompson, CPC, CMSCS, CCC, a consultant in Carlsborg, Wash.

If you are lacking such written documentation, cover your office by using a consultation request form that you fax to the requestor's office to be completed and sent back, recommends Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, PMCC, medical coding instructor at Orion Medical Services in Eugene, Ore.

Don't forget: Make sure your pulmonologist sends a written report to the requesting physician that describes his findings and recommendations. Attach a copy of this report to the patient's file. In a perfect world, the requesting physician should respond that he supports and authorizes the plan of care.

Technology can help: When the requesting physician and the consultant share the same EMR system, the requesting physician can merely indicate the request in his notes for the most recent patient encounter, which is accessible to the consultant, Pohlig explains. Additionally, the consultant does not need to create a separate report when the two physicians share a common record; she can simply electronically route a copy of the encounter to the requesting physician.