Advanced Search

Pulmonology Coding Alert

Choose the Right E/M Level for Proper Payments on New Patients

Published on Sat Sep 01, 2001

Pulmonology coders should be familiar with the five levels of new patient office or outpatient visit E/M codes (99201-99205) to receive fair and accurate reimbursement for the services performed.
 
Coding these cases can be complicated and tricky. Although each code specifies a certain amount of time spent with a patient and/or family, time is not usually the primary factor in choosing which code to apply to the visit unless counseling or coordination of care with other professionals is involved, says Walter ODonohue, MD, FCCP, FACP, chairman of the CPT committee of the American College of Chest Physicians (ACCP) and a representative to the AMA CPT advisory committee for ACCP. Rather, the key components of history, examination and decision-making dictate the level used for reimbursement.
 
Carol Pohlig, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania in Philadelphia, illustrates the difficulty in coding new patient visits, pointing out that part of the problem is the very fact that these patients are new and unfamiliar. Thus, the initial visit often requires more work and a higher level of decision-making than is actually documented. Even though the higher level is warranted, the physician inadvertently leaves out a key piece of information. For example, the physician may document a review of only eight or nine systems rather than the 10 actually examined, she says. This accidental omission drops the billing level by two, from 99205 to 99203, causing the pulmonologist to lose deserved reimbursement.
 
1. Level one: 99201. The simplest visit is coded 99201 (office or other outpatient visit for the evaluation and management of a new patient ...). A new patient visit covered by 99201 encompasses a limited problem, examination and treatment. For example, a 43-year-old male comes to a pulmonologist with symptoms of a mild cold. After listening to his lungs, the physician confirms the diagnosis but prescribes no medication. This represents straightforward medical decision-making -- the treatment option is self-limiting or minor, the amount of data reviewed was limited, and the risk to the patient was minimal.
  
2. Level two: 99202. A typical example of a visit covered by 99202 involves a 35-year-old female who presents at the pulmonologists office with cold symptoms. However, unlike the patient in the first example, this woman has a history of allergies, expanding the history taken and the examination performed.
 
In addition to listening to the lungs, the pulmonologist examines the ears, nose, mouth and throat to determine that the patient has a cold rather than allergies. Although the level of decision-making is the same as in the first example, more than one system is examined, resulting in the more complex code being used to bill for this visit. These first two codes, Pohlig notes, may be only infrequently used by specialists such as pulmonologists because they are concerned with medical conditions usually managed by the patients primary-care physician.
 
3. Level three: 99203. The third level is covered by 99203. For example, a 67-year-old woman presents herself at the pulmonologists, thinking she has a cold. After determining that the lungs are not affected, the doctor examines the eyes, ears, nose, mouth and throat to diagnose the patient with allergic rhinitis (477.9), not a cold, for which the physician recommends the over-the-counter drug Sudafed. This visit is billed 99203 because of the detailed exam given to the patient. The complexity of decision-making is low because this is a new problem with a treatment option that provides low risk of complication and/or morbidity or mortality to the patient.
 
4. Level four: 99204. Code 99204 involves a medical problem resulting in moderate risk to the patient, for example, an asthmatic with a mild exacerbation (493.92). The pulmonologist, after examining the patient and reaching the diagnosis, would adjust the bronchodilator therapy, i.e., prescription-drug management.
 
5. Level five: 99205. This is the most complex code. For example, a 36-year-old asthmatic with a severe exacerbation presents at the pulmonologists office. The physician provides inhalation therapy for acute airway obstruction and prescribes steroids. However, the patient has a history of diabetes and is asked to perform frequent finger sticks to monitor the effect of the steroids on his blood sugar. This visit fulfills the complexity of medical decision-making requirements for a level five because he is suffering from a chronic illness with severe exacerbation, and his drug therapy requires monitoring for toxicity.
 
Detailed documentation is very important when billing new patient visits to ensure that a practice realizes the full reimbursement it deserves. Pohlig emphasizes that pulmonologists must make sure they write down everything to eliminate inadvertently omitting services performed.
 
She suggests templates as a practical way of adhering to documentation. Templates provide reimbursement cues that allow physicians to document for billing without having to memorize the guidelines in addition to incorporating valuable information for clinical care. Pohlig also suggests that practices designate someone to keep up with the guidelines and revise the templates as needed as well as to serve as an internal auditor, offering possibilities for improvement in the system.
 
A practice may find itself billing one level more frequently than others, which may trigger an audit; but if the documentation is complete, it can pass any review of the material requested.

Other Articles in this issue of

Pulmonology Coding Alert

View All