Pulmonology Coding Alert

You'll see higher payments as a result

If your pulmonologist provides consultations, take note of the CPT deletions of follow-up and confirmatory consultation codes that go into effect on Jan. 1. The good news about these changes is that you may actually see $10 to $12 more on each in-patient follow-up visit.

CPT 2006 Also Clarifies Modifier 25

When the CPT updates take effect, pulmonologists will face two major E/M changes. CPT 2006 will:

• delete follow-up inpatient consultations (99261-99263, Follow-up inpatient consultation for an established patient ...) and confirmatory consultations (99271-99275, Confirmatory consultation for a new or established patient ...)

• clarify the explanatory text for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to specify that documentation must support the significant and separate E/M claim.

What You Report Instead

Remember that you will begin reporting all follow-up inpatient care with subsequent hospital care codes 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...), but the deletions don't change the way you report the physician's initial inpatient consults. You will continue to bill those as 99251-99255 (Initial inpatient consultation for a new or established patient ...).

The elimination of the follow-up inpatient consultation codes will make coding of inpatient visits easier for physicians. "These codes were rarely used correctly and so put physicians at a good deal of risk when they were used," says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb. And carriers rarely reimbursed appropriately and many insurers did not reimburse at all for follow-up consultations, Bucknam adds.

How it works: When your pulmonologist receives a request for a consult in the inpatient setting, you may claim an initial inpatient consult (99251-99255) for the visit. If your physician sees the same patient during the same inpatient stay, you should report subsequent hospital care codes (99231-99233), not follow-up inpatient consult codes (99261-99263) as you would have in 2005.

Example: Another physician asks your pulmonologist to see a newly hospitalized patient with chronic obstructive bronchitis and a new right lower lobe (RLL) infiltrate accompanied by fever, cough and yellow sputum. Your physician diagnoses pneumonia and starts the patient on antibiotics. Four days later, the attending physician asks that the pulmonologist see the patient again to outline a home-treatment program before discharge.
 
You should charge an appropriate level of consult for the first visit (99251-99255) and a subsequent hospital care code (99231-99233) for the second visit.
 
Use ICD-9 codes 486 (Pneumonia, organism unspecified) for the pneumonia if your physician didn't identify an organism, and use 491.20 (Obstructive chronic bronchitis, without exacerbation), 491.21 (Obstructive chronic bronchitis, with [acute] exacerbation) or 491.22 (Obstructive chronic bronchitis, with acute bronchitis) for the chronic obstructive bronchitis and emphysema depending on whether the patient had an accompanying acute exacerbation or acute bronchitis. 

Deletions Increase Pay But May Cause Confusion
 
The deletion of 99261-99263 and 99271-99275 is sure to make your coding easier and more profitable, but it may also make your coding more complicated.

Advantage: Luckily, this change will result in a pay increase for your physician: Codes 99231 and 99233 pay $11.75 more than 99261 and 99263, based on the 2005 fee schedule. And 99232 reimburses $10.23 more than 99262.
 
Problematic: There is no clear answer as to which code you should use instead of the deleted confirmatory consultation codes. A confirmatory consultation could qualify as an office visit, an outpatient consultation, or an inpatient consult.

If the patient requires a second opinion before surgery and the visit meets all the requirements for a consult initiated by another physician, bill it as an office or inpatient consultation (99241-99245 or 99251-99255) based on the place of service. Otherwise, if the patient is the sole requestor of the service, bill it as a new patient office visit or inpatient visit (99201-99205 or 99231-99233).

If the physician, or another physician of the same specialty within the group, has seen the patient within three years, you may still report a consultation as long as the requirements of a consultation are met (physician request, service rendered, report provided to requesting physician), and the requesting physician from your group does not possess the same skill set (eg., a general pulmonologist seeking advice on a transplant candidate). Otherwise, you should use the established outpatient visit codes (99211-99215).

How the patient came to see the doctor and the setting of the visit will drive the type of E/M service you report. To determine the appropriate code, look at the encounter's site of service and its consultation qualifications. If the visit meets a consultation's three requirements--request for opinion, rendering of services, and reporting back to the requester--you should report a consult code.

The other plus for coders is that the office visits have time associated with them, says Cheryl Scott, CPC, CPC-H, CCS, CCS-P, coding consultant with the Health Texas Provider Network in Dallas. "The confirmatory consults had no time association, so the providers were prevented from billing for counseling/coordination of care, which many of the confirmatory consults turn out to be," she says.

Caution: Remember that some carriers will not reimburse for a second consultation from a second pulmonologist if the patient has the same problem or diagnosis, or if the consultations fall within a specific time period. You may want to request that the patient sign an advance beneficiary notice (ABN) if you suspect non-payment because of this.

Additional E/M CPT Changes

January's update also clarifies the requirements for modifier 25. The new language states that documentation must satisfy "the relevant criteria for the respective E/M service to be reported."

This solidifies most coding experts' recommendations that you should be able to lift the E/M documentation from your notes and it should stand as a completely separate service from what the physician performed during the procedure.

"There still is a lot of confusion about when it is and is not appropriate to bill an additional service and append the 25," Scott says. "The additional clarification may also give additional documentation to force insurance companies to follow the CPT guidelines."

CPT also adds codes for initial nursing facility care (99304-99306) and a miscellaneous code for "other nursing facility services" (99318). And you'll have new codes for domiciliary, rest home (e.g., assisted living facility) or home care plan oversight services (99339-99340).