Pulmonology Coding Alert

If you glean anything from CMS's recent CERT report, it's that you have to buckle up your coding for NPP and support staff services. We're here to help you stay on track with your E/M coding by sharing three common questions and answers.

Avoid In-Hospital Incident-To Question: How should we code a nonphysician provider's (NPP's) report of a consult that she performs on a hospital inpatient? Is incident-to consult billing allowed for inpatient NPP services?

Answer: Incident-to is not allowed in the hospital at all, says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC Departments of Surgery and Anesthesiology. "Shared/split visits are permissible in the hospital setting; however, not for consultations," Hvizdash advises."Unless the physician performed his/her own separate and complete consultative service, the NPP would bill the consultation under his/her own provider number and select a visit level only based on the NPP documentation. From Medicare, the reimbursement would be 85 percent of the physician fee schedule."

Question: I know that a pulmonologist can share an E/M visit with a NPP. The NPP may take the history and perform some preliminary work before handing off the patient to the pulmonologist for the exam. Does this apply for consult services as well?

Answer: "When billing consultation services (99241-99245, Office or Other Outpatient Consultations, or 99251-99255, Inpatient Consultations), the physician can only consider the NPP's documented past, family, and social histories (PFSH), as well as the review of systems (ROS)," Berman (Hvizdash) says. "Alternatively, the NPP could note his or her visit in the chart, making a statement that the doctor will also see the patient."

Keep in mind: The pulmonologist must reference back to the PFSH and ROS (which he wants to use toward the reported level of service). The physician must perform and document his/her own HPI, physical exam and decision making in order to report a consultation in the physician's name.

Tip: Most other E/Ms may be shared/split between a physician and NPP. When permitted, the NPP performs and documents the service. "However, the note must also include proof that the physician saw the patient," (Berman) Hvizdash says. "The doctor can't just write that the records were reviewed or tests were viewed; but a face-to-face encounter with the patient must be evident within the note written by the MD."

Documenting a comment that the "patient was seen and examined by me," along with a comment on the extent of the physician's participation and a dated physician signature, can typically satisfy shared/split requirements, notes Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Check Payer Rules for 99211

Question: If a new patient presents for an office visit, sees the nurse but then has to leave suddenly, can we report 99211 (Office or other outpatient visit for the evaluation and management of an established patient,  that may not require the presence of a physician. Usually the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) for that visit? Also, can we bill 99211 for prothrombin time testing that the nurse performs on an established patient if the patient requires a brief evaluation?

Answer: There is no one complete source for the correct use of 99211, says Quinten A. Buechner, MS, MDiv, CPC, ACS-FP/GI/ PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. "Each payer does its own thing. CPT hasn't been very helpful either, so some practices avoid using the code," he explains. "That is a shame because just five encounters a week adds up to about $5,000 a year."

New patients: You'll find code 99211 listed under the established patient office visit codes, so you should not report it for a new patient.

Prothrombin time (PT): Under Medicare rules, you can report 99211 for PT testing if you meet the following requirements, Buechner says:

• Your practitioner provides face-to-face medication management.

• Your documentation establishes a need for clinical evaluation and management of significant new symptoms or clearly demonstrates how the relevant lab information was used to modify therapy.

• You list current medications with a notation of compliance. Indicate the pulmonologist's/practitioner's evaluation of the labs and recommendation for therapy. Clearly note the identity and credentials of the staff and pulmonologist/practitioner.