Pulmonology Coding Alert

Hint: New vs. established patient rules may be trickier than you think.

Your pulmonology practice sees patients for E/M services every day, and you probably know the regulations from memory. But from time to time, you’re likely to see some E/M questions crop up that confound you.

Several pulmonology coders have submitted E/M coding questions to Pulmonology Coding Alert recently, and we’ve got the answers with references straight from CMS to help guide your claim submissions.

1. Should We Choose 1995 Or 1997 Guidelines?

Question: We have traditionally used the 1995 E/M guidelines when making our code selections, but our office manager just went to a seminar where she heard that the 1997 guidelines were better suited for pulmonology practices when it comes to the exam. Is this accurate? Will it make a big difference for us to change?

Solution: Both sets of guidelines help you determine which exam level you performed: Problem-focused, expanded problem-focused, detailed, and comprehensive. But the exam element is the most significant difference between the two sets of guidelines.

1997:  The 1997 guidelines include specific physical exam elements that must be addressed in the documentation, both for a general multi-system exam and for single organsystem examinations. If a physician addresses elements other than those specified in the guidelines, the physician will not necessarily receive credit for those elements in the level of service. Also, if the language pertaining to an exam element included in the documentation differs from the language included in the guidelines, an auditor who has not had much clinical experience may inadvertently exclude the element from being credited in the level of service.

1995: The 1995 guidelines are much more general and, therefore, much less restrictive in a way. They allow the pulmonologist to make any comment in any of the organ systems he examines. What the physician examines within the systems and the wording he or she chooses to document are ultimately decided by the physician.

You don’t have to pick one set of guidelines and stick with them every time you code an E/M service. You can switch between 1995 and 1997 from one service to the next, choosing whichever set of guidelines is most advantageous for each encounter, says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh.

Essential: The key, however, is that you have to use either 1995 or 1997 exam guidelines for a single encounter, with one exception. “For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter,” CMS says in its MLN Matters document, Evaluation and Management Services. “However, beginning for services performed on or after September 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service,” the document notes.

Therefore, the answer of which guidelines to use will depend on your provider and how he documents each element of the E/M service. An auditor is required to review services with both sets of guidelines, and assign the most favorable result towards the final visit level, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

2. Do New Patient Rules Span Sites?

Question: Our pulmonologist is on rotation at the hospital once a week. He sees patients there who may not necessarily be members of our practice, but sometimes they later join our practice. Since they were never seen in our office before, can we count them as new patients?

Solution: 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 sinceyour 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 three years (36 months) the patient could be considered new.

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. “If a professional component of a previous procedure is billed in a three-year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit,” CMS says in Transmittal 1231.

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. 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.

If, however, the pulmonologist performed an E/M service on the patient in the hospital once and then saw the patient in the office two years later, that patient would be established, since he performed a face-to-face service on the patient within the last three years.

3. What If Inpatient E/M Doesn’t Meet 99221 Requirements?

Question: Our pulmonologist saw a hospital patient. His history and medical decision-making (MDM) were sufficient to report 99221, but he did not document any elements of physical exam. We just reminded him that all three elements (history, exam, MDM) are required for inpatient visits, but for this documentation that we have in front of us, what can we report? Is 99499 our best option?

Solution: According to MLN Matters article 7405, “In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT^® codes (99231 and 99232) could potentially be reported for an E/M service that could be described by CPT^® consultation code 99251 or 99252.”

You should reserve 99499 (Unlisted evaluation and management service) for situations when no other Medicare-payable E/M code that describes the service, the MLN Matters article says. “Reporting CPT^® code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Reporting/billing under these circumstances are deemed to be unusual.”

Therefore, if the visit is such that you would previously have reported it with a consultation code (before Medicare stopped accepting them), you can report a subsequent hospital care code if your documentation satisfies the requirements for it.

Resource: To read the CMS guidelines, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7405.pdf.