Pulmonology Coding Alert

Pulmonologists may not perform surgeries in the hospital often, but they certainly see hospital patients frequently, and knowing how to report those E/M visits properly is essential to your claims success. If you've got questions about inpatient E/M coding, we're here to help.

Background: Last month, Pulmonology Coding Alert shared the news that pulmonologists logged among the highest subsequent hospital visit error rates based on the latest CMS Comprehensive Error Rate Testing report. Several readers wrote in and asked our editors follow-up questions about coding hospital visits, and today we've got the answers to ensure that you're reporting these services accurately every time.

FAQ 1: When Can You Report 99221 and 99238 Together?

Question: Can we bill 99221 and 99238 on the same day under any circumstances? For example, the admitting physician saw the patient in the morning (99221). Then, later that afternoon, the admitting physician returned to discharge the patient (99238). Are there any modifiers we can use?

Answer: No. According to the Correct Coding Initiative (CCI) Edits, you cannot bill 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity ...) together with 99238 (Hospital discharge day management; 30 minutes or less).  This CCI edit includes a modifier indicator of 0, which means you cannot use a modifier to override the edit under any circumstances.

Although 99238 is a hospital discharge code, in your case, it is not the appropriate choice. According to CPT^®, you should only use 99238 to report services provided to a patient on the date of discharge "if other than the initial date of inpatient status."

Since the physician in this example admitted and discharged the patient on the same day, CPT^® directs you to choose a hospital service code such as 99234, 99235, or 99236 rather than the 99221/99238 combination. However, Medicare has specific requirements for 99234-99236, says Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

"In order to report a code from this category, the patient can only be admitted to observation or the inpatient setting for one calendar day, and the duration of stay (i.e., the duration between the admission order and the discharge order) must be a minimum of eight hours," Pohlig said. "Additionally, the pulmonologist must provide and document both face-to-face components of this service, the admission encounter and the discharge encounter."

FAQ 2: Do You Know CMS' New Policy on Medical Student Documentation?

Question: Our pulmonologists complain about having to re-document the elements of E/M services they perform in the hospital, even though their medical students have already documented it. Is there a way around this?

Answer: Yes, fortunately there is now a way around at least part of the documentation requirements.

Background: CMS has long allowed students to document services in the medical record, but up until now, CMS policy has dictated that teaching physicians can only refer to the students' documentation for the review of systems (ROS) and/or past family/social history (PFSH). "The student's documentation of physical exam findings or medical decision-making (MDM) could not be used as part of the attending physician's note," said Todd Thomas, CPC, CCS-P, president of ERcoder, Inc., in Edmond, Oklahoma.

"If the student's documentation included history of present illness (HPI), exam, or medical decision-making (MDM) information, the attending physician had to perform or repeat these elements performed by the student and redocument the HPI, physical exam and medical decision-making activities of the service," he said.

New way: According to a new CMS policy, which went into effect Jan. 1, "Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work."

Therefore, the following are the important features that physicians must note under the new policy, Thomas advises:

• The attending physician must be at the bedside while the student performs any of the E/M elements.
• The attending physician must personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service being billed.
• The attending physician may verify student documentation of any or all E/M elements in the medical record, rather than re-documenting information that has already been documented.
• Attestations to confirm the presence and performance of the necessary elements should be documented by the attending physician.

It is important to understand that this policy change does not affect how the physician and student encounter with the patient is performed, Thomas advises. The change only applies to how the documentation of the encounter can be performed.

"This revised policy seems to streamline the documentation process and ease administrative burdens on physicians, while also adding the necessary component of training of medical students on the proper documentation of E/M services," Thomas says. "This is a very substantial policy change by CMS and could have a drastic change on the documentation workflow if attending physicians choose touse the documentation by the students to support their E/M services."

FAQ 3: Can You Differentiate Inpatient From Observation?

Question: Our pulmonologist admitted a patient to the hospital at 10:30 a.m. A different pulmonologist, also from our practice, discharged the patient at 3:30 p.m. The admitting physician wants to bill an inpatient code, while the discharging physician wants to bill an observation code. Which is correct?

Answer: The answer here depends on a number of factors, including if the patient was admitted as an inpatient or observation, and, the length of time the patient spent during the stay.

You could document a patient admitted and discharged by physicians in this scenario with 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...), which covers both inpatient and observation statuses. However, this requires the patient stay to last at least eight hours (as described in FAQ1).

But if the patient was admitted less than eight hours on the same day, you would bill only one service, using 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient ...). The pulmonology group could only bill 99218-99220 and 99217 (Observation care discharge day management ...) when billing for a stay that spans two calendar days, and the corresponding physician service was provided on each day.

Why? Medicare and payers who follow its guidelines abide by the CMS decision that when "a patient receives observation care for less than eight hours on the same calendar date," the physician should report "from CPT^® code range 99218-99220" (Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2282CP.pdf).