Pulmonology Coding Alert

Will consultations receive reimbursement? Find out.

Last month, Pulmonology Coding Alert introduced the revised office/outpatient consultation evaluation and management (E/M) codes and guidelines in the AMA’s 2023 CPT^® code set. In this second part of the series, you’ll learn how to choose the level of medical decision making (MDM), what to do when a provider initiates diagnostic testing during the consultation, and if payers will even reimburse for consultations.

Before learning about Part 2, catch up by reading “Receive Advice for Office/Outpatient Consultations in 2023 (Part 1)” here: www.aapc.com/codes/coding-newsletters/ my-pulmonology-coding-alert/em-2023-receive-advice-for-officeoutpatient-consultations-in- 2023-part-1-172955-article.

Determine the MDM Level for Patients With Multiple Conditions

If a patient visits your pulmonology practice for a consultation, several factors influence your code selection. The patient may be experiencing multiple new or established conditions at the time of the encounter, which alone would not determine the level of MDM. However, whether the conditions are acute or chronic is likely a key factor. “2023 MDM is similar to the 2021 rules in that the ‘new or established’ conditions do not matter as much as whether those problems were addressed and managed,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Of course, selecting the level of MDM requires more than determining the number and complexity of problems addressed at the encounter. “With the revised MDM calculations, the coder must also consider the amount or complexity of data to be reviewed and analyzed, as well as the risk of complications or morbidity or mortality of patient management. Two of these three areas must meet or exceed the requirements for any given level in order to assign an E/M code,” says Nancy Clark, CPC, COC, CPMA, COPC, CPC-I, AAPC Fellow, senior manager at EisnerAmper Advisory Group in Iselin, New Jersey.

Scenario: A patient visits your pulmonology practice with an acute exacerbation of their chronic asthma, as well as prescription management. This patient experiences multiple asthma exacerbations during the year. During this consultation, the pulmonologist decides to adjust the patient’s medication therapy after discussing the patient’s condition with the patient’s primary care physician (PCP).

This scenario could qualify as moderate complexity since one chronic illness with exacerbation was addressed, the physician discussed the patient’s management with their PCP, and the provider made an adjustment to the patient’s medication. The provider met moderate complexity in all three areas, even though two areas would have sufficed.

Code Diagnostic Testing During a Consultation

During an outpatient consultation, the provider may decide to perform a diagnostic test to receive up-to-date results prior to determining a treatment plan. According to the Consultations guidelines, “A physician or other qualified health care professional consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.”

Scenario: During a consultation with a patient for treatment of their chronic obstructive pulmonary disease (COPD), the pulmonologist performs a spirometry test without a bronchodilator. The pulmonologist documents that since the patient has only been evaluated by their general practitioner (GP), the pulmonologist wants to establish a baseline for the patient’s condition prior to treatment.

Take a look at the following tips for knowing if you can report the consultation and diagnostic testing codes together:

• Tip 1: Show medical necessity.

Review the provider’s documentation to ensure the diagnostic test and the E/M visit are both medically necessary and documented.

• Tip 2: Check National Correct Coding Initiative (NCCI) and payer edits.

Review NCCI and payer-specific edit pairs to confirm whether your selected CPT^® codes are bundled and shouldn’t be separately reported at the same encounter.

For this visit, you’ll need to report the appropriate consultation code along with the spirometry CPT^® code. Depending on what was determined in the consultation visit, you may assign either of the following 2023 E/M codes:

• 99243 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.)
• 99244 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.)

Then you’ll assign 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation) to report the spirometry test.

In the scenario, the pulmonologist documented the need for the spirometry test during the consultation. Additionally, 94010 isn’t bundled with 99243 or 99244 in the NCCI edit pairs (based on fourth quarter 2022 edits), which means you can report the appropriate codes for the encounter. As the next section explains, not all payers accept consult codes, requiring you to use another E/M code, such as 99202-99215. NCCI does have edits for 94010 with 99202-99215, which you may override with a modifier.

Modifier needed: If the provider’s documentation supports medical necessity, you may need to append the E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service), depending on your individual payer’s preferences. “A payer may request modifier 25 to be added to the visit code, but modifier 25 typically wouldn’t be required for visits with diagnostic tests that do not have a ‘global period’ (94010 has XXX global period),” Pohlig says.

Will Consults Receive Payment?

While the CPT^® code set includes consultations, many providers misunderstand the CPT^® concept of consultations, and the codes are often used inappropriately, such as when a physician or other provider refers a patient to a specialist. “Per CPT^®, the key requirement of a consultation is that a physician or other appropriate source requests an opinion or advice from a physician; and that physician renders the advice and/ or opinion back to the requesting provider,” Clark says. CPT^® revised the 2023 E/M consultation guidelines to eliminate the “transfer of care” term since the term may have caused confusion as to the appropriate use.

At the end of the day, the real question is if payers will even reimburse for consultations. “Medicare does not recognize consult codes, and will likely still not recognize them,” Pohlig says. This is due to, in part, the misuse and under documentation of consultation codes. In fact, the recently released calendar year (CY) 2023 Medicare Physician Fee Schedule proposed rule indicates the Centers for Medicare & Medicaid Services (CMS) is proposing to “maintain the current billing policies that apply to E/Ms while we consider potential revisions that might be necessary in future rulemaking.” This is in addition to proposing to adopt the other E/M visit coding and documentation changes (www.federalregister.gov/ documents/2022/07/29/2022-14562/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other).

If a payer doesn’t recognize consultation codes and a practice submits one, the practice will likely receive a denial indicating the procedure code is not covered. “In this case, the practice has the opportunity to identify the issue, correct the claim, and resubmit the appropriate new or established patient code,” Pohlig says.

“For payers that do not accept consultation codes, the appropriate level of new or established patient E/M service should be utilized,” Clark says.

The provider will need to report a new or established patient E/M visit code, depending on if the patient has received face-to-face services from a provider in the practice within the last three years.

• New patient: 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …)
• Established patient: 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …)

Of course, you should review your individual payer policies to see how office/outpatient consultations should be reported to receive proper reimbursement.