Pulmonology Coding Alert

Avoid making the same mistakes these doctors made.

You see a patient in the hospital and perform her initial workup, then report the appropriate E/M code. Easy, right? Not exactly. According to Medicare's most recent error rate data, pulmonologists logged among the highest improper payment rates for initial hospital visits.

Background:  CMS issued its "Appendices for the Medicare Fee-for-Service 2016 Improper Payments Report" in December as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the biggest errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found an 11.7 percent improper payment rate among Part B claims during 2016, with the majority of those being classified as overpayments to providers.

Particularly troubling for pulmonology practices is the 28.1 percent error rate seen among this specialty for initial hospital visits, which totaled $42.8 million in projected improper payments. This was the fourth highest error rate in this category, topped only by gastroenterologists, cardiologists, and family practitioners.

Pulmonologists fared slightly better when it came to subsequent hospital care, with a 16.3 percent error rate, and overall, pulmonologists logged a 12.2 percent error rate among Part B claims submissions, which was higher than the national average when all specialties were combined. Among the Part B issues that reviewers noted as being problematic were visits for COPD, pulmonary edema, and respiratory failure, but these errors paled in comparison to that sky-high initial hospital care error rate.

Read on to ensure that your initial hospital visits don't land you in trouble by following our four expert tips.

Tip 1: Know Your Payer

A common misconception involves whether you can find an admit code CPT^® manual, but you cannot - the initial inpatient code is what you should use when you admit a patient to the hospital.  

The admitting physician should report a code from the 99221-99223 range for his care if he documents the elements contained within the codes (appropriate history, exam, and medical decision-making). He is not billingfor the admit itself - he's billing for the initial care that he provides, based on the documentation.

CPT^® states that the initial hospital care codes "are used to report the first hospital inpatient encounter with the patient by the admitting physician." However, Medicare (and Medicare Advantage plans) treat initial hospital care codes differently, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. "Before 2010, only the admitting physician reported initial hospital care codes, and specialists who saw the patient separately billed inpatient consultation codes," she says. "Since CMS no longer recognizes the consultation codes, consultants may report initial hospital care for the initial visit from that specialty group during a patient's stay."

In contrast, commercial insurers will only pay one claim per hospital admission with an initial inpatient code. For instance, the policy for Blue Cross and Blue Shield of Florida says it will pay "for one initial hospital care service per hospital stay per patient. If multiple claims are received with one of the initial hospital care services CPT^® codes, the first claim received will be allowed and the subsequent claim(s) will be denied with instruction to rebill with the appropriate subsequent hospital care code."

Private payers may maintain consultation codes for the non-admitting physicians of different specialties who are called in to assist with care, Pohlig says. "If the documentation meets consultation coding requirements, then 99251-99255 may be selected instead of 99221-99223."

Tip 2: When Multiple Specialists Visit, Look to Modifier AI With Medicare

Because Medicare allows multiple specialists to charge for a patient's initial hospital care, Medicare created modifier AI (Principal physician of record) to show which doctor admitted the patient. The other doctors seeing the patient for consultative services will charge for their services with a code from the same series but with no modifier to report his first visit with the patient.

In order to demonstrate the medical necessity of each specialist providing care to the patient during the stay, the primary diagnosis should reflect the primary problem for which each specialist is responsible, Pohlig says. "If two physicians have the same diagnosis listed as their primary diagnosis (e.g., J44.1, Chronic obstructive pulmonary disease with [acute] exacerbation), Medicare may want to review the notes to see if the care is different and distinct, or overlapping," she adds.

Tip 3: Not All Admissions Are Inpatient

Make sure the patient your pulmonologist attends has been admitted as an inpatient, since not all stays qualify as "inpatient" status. Even if the doctor saw the patient in the hospital, the stay may not meet criteria for admission as an inpatient.

If the stay only qualifies for observation care and the patient is seen for an initial encounter, Medicare and its followers require the pulmonologist to use the new or established patient codes (99201-99215) since the pulmonologist is the consultant and not the attending physician of record. Non-Medicare payers may allow the outpatient consult codes to be used (99241-99245), if recognized. The place of service on the claim in this situation is 22 (Outpatient Hospital), Pohlig says.

Inpatients include patients admitted to hospitals, partial hospital settings, or nursing homes. Your pulmonologist's consultations in the ED or for patients admitted to observation status are not considered inpatient services.

4. Readmissions Typically Warrant New Inpatient Period

If the patient is discharged and later readmitted at another time, you can typically report a code from the 99221-99223 series again. "Each admission should have its own initial inpatient code," says Rebecca L. Odell, CPC, CPCO,  CPMA, CPB, CPC-I, billing team leader with Advanced Health Partners, Inc. in New Windsor, N.Y. and president of the AAPC's New Windsor chapter.

"If the patient returns a day or a week later, an initial workup will still need to be completed," Odell adds. "If the patient is returning a week later and the condition is worse, the doctor needs to find out why it is worse and what happened in the week that made the condition worse. Tests may be ordered that were not performed during the first admission or repeated," she says. For Medicare, initial care codes can be reported by the attending of record, and consultants.

If, however, a non-Medicare patient is readmitted and your physician sees the patient during that hospitalization but is not the admitting physician, then you should choose from the inpatient consult codes, 99251-99255, or follow-up hospital visit codes, 99231-99233, instead.

Resource: To read the full CERT document indicating pulmonologists' high error rate for inpatient visits, check out the Medicare website at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/AppendicesMedicareFee-for-Service2016ImproperPaymentsReport.pdf.