Pulmonology Coding Alert

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 [...]