Pulmonology Coding Alert

These regulations won’t change in 2021, so ensure you know them well.

As every pulmonology practice is aware, the office/ outpatient E/M code regulations are set to change dramatically when 2021 arrives. However, although the way you select your codes will be different, some central tenets to the E/M guidelines will not change.

Therefore, it’s a good time to ensure that you know the foundational aspects of how to report E/M services. This will help you enter the new year with fewer challenges ahead of you. Check out these three frequently asked questions to see if you know the answers.

Can You Report Inpatient Codes Based on Time?

Question 1: The pulmonologist sees a cystic fibrosis patient in the hospital and does not maintain thorough notes about the history or exam. However, they document that they spent 36 minutes on the encounter and discussed treatment options with the family. The visit does not constitute critical care, so how can you bill this service?

Answer 1: You may be able to bill this encounter based on time, since the physician noted the time spent and what was discussed. However, you must ensure that the documentation is clear about how much of the visit was spent in counseling/care coordination.

Background: Because 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components…) is the highest level of subsequent hospital care, documentation typically requires two of these three criteria: A detailed history, detailed exam, and/or high complexity medical decision making (MDM). However, you can also report 99233 based on time if you meet the documentation requirements. CPT^® assigns a 35-minute time threshold to this code. Although many coders think of time-based E/M coding only as an outpatient strategy, it’s perfectly acceptable to use time as your overarching code selection criteria in the inpatient setting, if you meet the guidelines.

Ensure that the following three factors are documented in the hospital record if you select 99233 based on time:

1. The total time spent during the inpatient encounter (which should be at least 35 minutes for 99233)
2. The time spent counseling/coordinating care (which must exceed 50 percent of the total visit time)
3. A description or summary of the counseling/ coordination of care provided.

Keep in mind that the total time for an inpatient is considered as the face-to-face time plus the unit/floor time spent in care directly related to the patient.

For instance, the documentation would say something like: “Total visit time was 35 minutes; 20 minutes of that visit was spent counseling the patient and her parents about potential treatment options and management techniques for cystic fibrosis, as well as prognosis. Answered multiple questions and provided them with educational information.”

Although this question indicates that the pulmonologist documented the total time spent and what was discussed, there’s no indication that the physician spent at least half of that time on counseling/coordinating care. In these situations, you may not be able to bill based on time unless you have a record of how much time was spent counseling/coordinating care.

Discover How to Interpret the 3-Year Rule

Question 2: Your pulmonologist leaves another practice and joins yours, bringing several of their previous patients with them. Because the physician is seeing the patient in a new setting, can they bill them as new patients, even though they saw them within the last three years at their previous practice?

Answer 2: No, a physician should not be reporting new patient codes if they saw the patients within the last three years, even if they last saw those patients at a different practice.

CPT^® rules don’t say anything about separate practices. Instead, the guidelines state, “A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

These guidelines are meant to uphold and clarify the following principles, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania:

A physician cannot see a patient in a former practice and bill them as a new patient when the physician changes practices; and

A patient cannot be considered a new patient if they were seen in the same practice by a member of the same specialty/subspecialty. However, a provider in a different subspecialty (within the same or at a different practice) can report a new patient code. “For example, a pulmonologist and an allergist belong to the same group practice,” Pohlig says. “When the pulmonologist sends the patient to the allergist in the group for the first time, the allergist can bill for a new patient visit, despite both providers being part of the same group practice.”

Understand the 99211 Rules

Question 3: Your physician assistant sees a patient for a quick medication check visit and reports 99211. Is it acceptable for a PA to report a code that’s generally reserved for nurses?

Answer 3: Yes, 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services) is not reserved for nurses — any clinical staff member can report it when it’s the most appropriate code based on the documentation, and that won’t change in 2021. This includes physicians, nurse practitioners, and physician assistants, “assuming that the service and associated documentation does not meet the criteria to bill for a higher level of care that includes history, exam and medical decision making,” Pohlig says.

Any qualified providers who are employees of the practice (such as medical assistants, licensed practical nurses, technicians, and other aides) and are working under the physician’s direct supervision can provide services to patients under the incident-to umbrella using 99211. If reporting 99211 incident to, the physician must be present in the office space, and the auxiliary personnel must be qualified to perform the service. For your practice to report any service, including 99211, as an incident-to service, the nurse would have to be monitoring a problem that the physician already evaluated, because you cannot bill incident-to if the nurse evaluates a new problem.

Prep for this change: Keep in mind that when the 2021 guidelines arrive, you will not be able to report 99211 based on time alone — it is the one exception to the overall office/outpatient code set in that regard. For that reason, CPT^® will be removing the time component from the code’s descriptor. The new descriptor will read “Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.”