Pulmonology Coding Alert

In addition to new codes for thoracentesis, smoking cessation and telephone E/Ms (see previous story), CPT also rewrote the descriptors for nursing facility care in its 2008 edition.

Impact: These revisions to the 99304-99318 code family may make reporting the nursing facility codes much less cumbersome. In past incarnations, CPT did not include time guidelines for coders to observe. The codes were listed based on the severity of the problems or the patient's status.

Now, each CPT entry for nursing facility care includes a typical timeframe for that level of visit. "The pulmonologist's impact of the nursing home codes comes mostly with the subsequent-day codes (99307-99310)," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Unless the pulmonologist is the primary physician managing the patient's total care, he would report his service as a consult, if the requirements were met, or bill solely with the subsequent-day codes, Pohlig says.

The new definition of 99307 reads, "Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A problem-focused interval history; a problem-focused examination; straightforward medical decision-making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 10 minutes with the patient and/or family or caregiver."

The last sentence of the definition, which provides a timeframe for 99307, was not part of the descriptor last year. "This change is a help to coders," says Quinten Buechner, ACS-FP/GI/PEDS, CPC, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

The rewritten codes will make the prolonged services codes easier to report: However, "the trick is getting the physicians to document the time spent in counseling and coordination of care," Buechner says.

The other revised codes in the nursing facility section of CPT 2008 that coders should be aware of are:

• 99308 -- ... an expanded problem-focused interval history; an expanded problem-focused examination; medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 15 minutes with the patient and/or family or caregiver.

• 99309 -- ... a detailed interval history; a detailed examination; medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Physicians typically spend 25 minutes with the patient and/or family or caregiver.

• 99310 -- ... a comprehensive interval history; a comprehensive examination; medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 35 minutes with the patient and/or family or caregiver.

Impact: According to Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa., the rewritten nursing care codes will be very beneficial to practices.

The new descriptors will allow providers to possibly code for a higher level of service -- if they spend more than half of the visit "providing health advice, education, and counseling," she says.

Remember: You might not report the first encounter with a nursing facility patient with subsequent codes, Pohlig says. "If the visit meets consultation requirements, the pulmonologist would report the inpatient consultation codes (99251-99255), then subsequent-day care codes for any further medically necessary visits," Pohlig says.

"If the consult requirements are not met, the pulmonologist only reports subsequent-day care from the first encounter," she says.

The biggest potential benefit of these rewrites will come when your pulmonologist conducts longer visits to the nursing facility, "where the provider deals with family or the patient for counseling and coordination of care," Buechner says.

Consider this example: The pulmonologist visits a nursing facility patient on oxygen who suffers from chronic obstructive bronchitis and emphysema. He visits the patient and her family members to discuss next steps and possible treatments. This counseling, and the subsequent coordination of the patient's wishes, takes 33 minutes, which was also the total duration of the visit.

Using the new nursing facility codes, you would report this encounter with 99310. Don't forget to attach 491.20 (Obstructive chronic bronchitis with emphysema; without exacerbation) to 99310 to represent the patient's condition.

When you file this claim, Buechner recommends that you document:

• total visit time

• a summary of topics discussed

• a description indicating that more than half of the total visit time involved counseling and coordination.