Pulmonology Coding Alert

Careful documentation and choosing proper language can mean the difference between getting paid for consultations and having to argue with insurance carriers over denials.

A consultation is a service provided by the pulmonologist whose opinion or advice is sought regarding a specific problem. It requires a request for the information and expertise from another physician or appropriate source. The consulting physician could initiate diagnostic or therapeutic services at the same or subsequent visits.

When one doctor requests an opinion or advice from another, thats when the consultation codes (99241-99245) should be used, states Jan Johnson, executive vice president of The Profile Group, a reimbursement and compliance advisory firm in St. Paul, Minn. To determine when to code consults, look for the following:

The patient has to have been sent by another physician asking for the specialists opinion;

The receiving doctor must examine the patient and document in writing what was done; and

The pulmonologist must then send written recommendations in a report back to the physician who initially sent the patient.

For example, a primary care physician (PCP) has a patient complaining of shortness of breath that has lasted more than a month and seems to be increasing in intensity. The PCP refers her to a pulmonologist and calls to request a diagnosis. The pulmonologist examines the patient, diagnoses the problem, and responds with a written suggested treatment plan.

This is a clear-cut example of a consult. Remember that the record must show the phone call from the requesting physician to your pulmonologist, and the pulmonology report needs to be written up, noted and returned to the PCP. (Tip: The request can also be documented in the letter back to the requesting doctor Thank you for requesting this consultation.)

The first thing insurance carriers look for is the name of the PCP who is sending the patient, says Carole Fatato, division coordinator at Cooper Hospital Pulmonary and Critical Care in Camden, N.J. If they dont have a referring physician, carriers automatically deny it [a consult], she warns.

Transfer or Consult?

Rules for consults require that the patients care remain with the PCP. On the other hand, the transfer clearly moves his or her care and treatment (and the record reflects this) from the initial physician to the pulmonologist. This occurs when the PCP requests the specific service prior to the patient being seen by
the pulmonologist.

Ray Painter, MD, of Physician Reimbursement Systems in Denver, says that the consult codes apply unless the specialist is asked to take over some or all of the care. If the requesting physician continues to see the patient, and the consulting physician accepts and agrees to manage an aspect of the care, then a transfer has occurred at that point, Painter says.

Medicare guidelines give several examples to indicate that total transfer of care is related to the specific problem in question only, not total transfer of the entire patient. However, there are differing opinions of what transfer of care means, and you should clarify with your carrier, adds Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

For example, the consulting pulmonologist diagnoses a chronic pulmonary disease. The report and records are returned to the PCP, and after careful consideration, he or she decides the pulmonology specialist would better serve the patient. The PCP would make a documented request. The consult would be coded and billed, and any subsequent care by the pulmonologist becomes an established patient visit (99211-99215).

Occasionally, however, the intentions of the sending physician are not clear. Even a written request can be confusing. When a doctor writes the request for a consult, the record should indicate clearly that I want your opinion, and thats all, says Pat Booth, RN, director of government relations for the National Association of Medical Direction of Respiratory Control. If the physician writes, I want the pulmonologist to evaluate and follow this patient, it should not be considered a consult, based on the intention behind the word follow, because a transfer of care has already occurred.

Similarly, pulmonologists who are billing for a consult should not write back to the sending PCP, Thank you for referring this patient to me. Booth says, That sounds like a transfer of care to the carrier. She adds that other notes made by the consulting doctor such as I will continue to follow, set off red-flag warnings for auditors.