Pulmonology Coding Alert

Although pulmonologists don't perform lung transplants, they do provide several services related to the procedure and they should ensure they are paid for each of them. When a pulmonologist has a patient with advanced lung disease that is no longer medically manageable, a lung transplant specialist (a pulmonologist who specializes in transplant care) may be consulted. The transplant pulmonologist assumes all care related to the transplant (candidacy screening, counseling, etc.). He or she reports the services to the hospital, which will then sort out which insurer to bill. This will depend on who insures the patient Medicare, private carrier, etc. at the time of the transplantation. Such services are considered hospital charges even if they are provided as outpatient services. Therefore, they are billed directly to Medicare through the organ-acquisition charge of the transplanting hospital or center. These preoperative evaluations, which may be performed by the patient's primary-care physician (PCP), should be billed using the standard E/M codes (99201-99205, new outpatient; 99211-99215, established outpatient; or 99221-99233, inpatient). In addition, the transplant pulmonologist can report consultation codes (99241-99245) when the general pulmonologist requests the transplant pulmonologist's opinion regarding the patient's candidacy.

Because of the complexity involved with evaluating a potential lung transplant patient, most pulmonologists commonly report the higher-level codes for their services. If the pulmonologist has an established relationship with the patient, he or she may not have to provide the same level of history and examination that may be necessary for a new patient. But as with any evaluation, the severity of the patient's condition does not dictate the level of service. The physician's documentation must drive the E/M coding. Note: Under the ambulatory payment classification system, hospitals are reimbursed based on CPT coding consolidated into one bill. Although the regulations do not affect physician billing directly, you should ensure that physicians carefully document and bill the correct CPT codes to report every service provided. However, this only applies to outpatient services. Inpatient services are guided by diagnostic-related group (DRG) billing. The pulmonologist performing pretransplant services would base the office or other outpatient E/M coding on the following: The complexity and number of underlying diagnoses of the pretransplant examination for the potential recipient The transplant center's contracted guidelines. The pulmonologist would report his or her services in the customary manner, either directly through the hospital or through a billing package to the carrier. The physicians involved with the transplant procedure may charge at different levels for each E/M service, but all cooperating doctors must submit their charges simultaneously. Generally, a hospital or other facility department or unit specifically oversees the physicians' simultaneous and timely charge submission. Use a Secondary Diagnosis When choosing the proper diagnosis code for the pulmonologist's [...]