Pulmonology Coding Alert

Face-to-face encounters are a must for an established status.

When your pulmonologist treats a previously seen patient, don't always assume you would report E/M services provided using established patient codes (99212-99215). Check out our advice on when to use new patient codes for a patient your pulmonologist has previously treated.

Use Time Specifications to Determine Status

One of the prime considerations that you will have to factor in when trying to determine if a previously seen patient should be billed under established or new evaluation and management codes is time elapsed since your pulmonologist last saw the patient or provided services.

Have a look at CPT®'s established patient definition: "An established patient is one who received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." "If the patient hadn't been seen by your pulmonologist in the last 3 years (36 months) the patient could be considered new," says Suzan Berman, CPC, CEMC, CEDC, Senior Director of Physician Services -Health Revenue Assurance Associates, Plantation, Florida.

"If the patient has been seen in the past by a physician or someone in his/her group, a new patient charge cannot be generated unless the patient has not been seen for three years or longer," says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. This indicates that if your pulmonologist has not seen the patient in the period of the past three years, then you can bill E/M services provided to the patient using new E/M codes (such as 99201-99205, Office or other outpatient visit for the evaluation and management of a new patient...).

Here is an example shared by Plummer: The pulmonologist sees a patient that was seen by his pulmonary group two years and 364 days before.  He/she would charge for an established patient visit.  If the patient was not seen until exactly three years from the last visit, the pulmonologist would charge a new patient visit for the encounter.  If the patient has been seen by an general internal medicine physician and not a pulmonologist within the previous three years, then the pulmonologist could charge a new patient visit code since no one in his/her specialty had seen the patient within three years.

Don't Base Patient Status on Location

When it comes to determining if the patient who sees your pulmonologist is new or established, location in which your pulmonologist provided services to the patient is not the deciding factor. So, if your pulmonologist provides an E/M service to a patient in a hospital where he consults and then provides a subsequent service in his office, you will have to report the subsequent visit at the office using relevant established patient codes (99212-99215).

Also, if your pulmonologist performs an initial hospital visit to the patient and another pulmonologist who has the same tax identification number provides subsequent E/M services in his office or in the outpatient department of the hospital, you will still have to bill the services using established E/M codes.

Reminder: In a multi-specialty practice, if your pulmonologist sees a patient that has already been previously seen by a cardiologist, the pulmonologist can report the E/M services provided using new patient codes even though the physicians in a multi-specialty group report services under the same tax ID.

Example: A newly hired pulmonologist sees a patient for shortness of breath. He takes a detailed history and performs a detailed physical examination. The patient has previously seen your new pulmonologist in another hospital in the past one year. You will have to bill the services provided by your new pulmonologist using established patient codes as your pulmonologist has previously seen the patient within the three year stipulated period. So you report the services using 99214.

Example2: A primary care physician in your multi-specialty group refers his patient to the pulmonologist in the group to assess the dyspnea symptoms that the patient is experiencing. Your pulmonologist performs a level-3 evaluation and management. Even though the patient has been previously seen by the primary care physician in your group (reports with the same tax identification number), you can report the E/M visit conducted by your pulmonologist using 99203 since the two physicians are designated as different specialties with the payer.

Observe That Face-to-Face is Must for Subsequent Established Codes

When determining the status of the patient as established, another factor that you need to bear in mind is that any professional services provided to the patient in the previous three years should be a face-to-face encounter. "The E/M service being billed when they first have that face-to-face encounter would be considered new," says Berman. "A diagnostic test interpretation does not preclude you from billing a new patient service the first time you see the patient."

So if your pulmonologist provides an interpretation for a test conducted without a face-to-face encounter with the patient and then sees the patient at a later date, you will bill the E/M service provided using new patient codes. "Interpreting a test on a patient does not constitute a patient encounter," says Plummer.  "Thus, a pulmonologist could interpret a set of PFTs on a patient on one day, see the patient as a new patient the next day (or the same day) and code a new patient E/M code for the visit." This holds good even if the patient is seen within the three year stipulated time of providing the interpretation services.

Example: Your pulmonologist provides interpretations for polysomnography conducted on a patient. The same patient visits your pulmonologist after six months with complaints of orthopnea. Your pulmonologist assesses the patient with a detailed history recording and a detailed physical examination. Since the first set of services of providing interpretations for polysomnography did not involve a face-to-face encounter with the patient, you will have to report the current E/M services provided to the patient using new patient codes. So you report the visit with 99203.