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Pulmonology Coding Alert

Ensure Proper Pretransplant Payment With Correct E/M Codes

Published on Mon Jul 01, 2002

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 initial evaluation of a patient to determine if he or she is a candidate for transplantation, you should report the patient's underlying condition. This may include chronic obstructive pulmonary disease (COPD, 496), pulmonary hypertension (416.0), cystic fibrosis (277.00) or pulmonary fibrosis (515).

    But when the pulmonologist performs the preoperative clearance examination, he or she should report V72.82 (Pre-operative respiratory examination). In addition, recording a secondary or the underlying diagnosis may also be helpful to show medical necessity. Although Medicare requires one diagnosis per line level of service on the CMS 1500 form, the secondary diagnosis may prevent claim denials.

    Minimum Benchmarks

    The minimum basic requirements for the transplant patient's pre-evaluation are usually established by the facility or organ-procurement company and are based on typical industry practices. The pulmonologist can order additional studies as medically indicated to confirm or eliminate a problem spotted in the pretransplant patient.

    Testing could include but not be limited to tissue typing (86805-86849), chest x-ray (71020, Radiologic examination, chest, two views, frontal and lateral), and electrocardiogram (ECG, 93000, Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). The patient is also tested for hepatitis (86708, Hepatitis A antibody [HAAb]; total; or 86709, IgM antibody) and HIV (86689, Antibody; HTLV or HIV antibody, confirmatory test [e.g., Western Blot]).

    And, the pulmonologist could report 71020 if he or she owns the x-ray equipment, points out Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the department of medicine at the University of Pennsylvania in Philadelphia. If the physician only interprets the chest x-ray, you should report 71020 with modifier -26 (Professional component) appended. Similarly, if the pulmonologist owns the equipment for performing the ECG, he or she could use 93000. If the pulmonary physician only interprets the ECG results, however, you should code 93010 ( interpretation and report only).

    Pulmonologists would likely not perform tissue typing or hepatitis and HIV testing, Pohlig says, adding that these services are usually outsourced to a lab. But the pulmonary physician may be able to report taking the blood sample for the testing using G0001 (Routine venipuncture for collection of specimen[s]) for Medicare and 36415* (Routine venipuncture or finger/heel/ear stick for collection of specimen[s]) for non-Medicare payers.

    Additional testing is performed for recipients who pose a risk of cardiac complications. In these cases, a stress test (93015-93018, Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress ) and an evaluation of the patient's ability to withstand a transplant may be conducted. They may also require a right heart catheterization (93501) to determine the condition of the heart for involvement or ability to withstand the transplant.

    Note: If anything unusual is detected on the screening chest x-ray, further tests would be ordered. Use 93010-26 ( interpretation and report only; professional component) if the facility owns the pulmonary function test equipment and the pulmonologist only interprets the results. The required lab and vascular studies vary among procurement areas, and physicians may order additional lab studies and tests based on the organ-procurement agency's mandates.

    The evaluation's complexity depends on the patient's motivation and the stipulations made by the primary payer. After the pulmonologist performs the pretransplant workup and if the patient is deemed acceptable for lung transplantation, the potential recipient's name is placed on a national transplant waiting list. If a donor has not been found at the end of a year, the physician may have to perform another extensive E/M service (re-evaluation) for the patient to ensure continuing acceptability.

    Coding for Counseling

    In addition to the standard services, pulmonologists frequently provide counseling for transplant patients. Consequently, you may be able to code these visits based on the time element. Two key factors to consider in these cases is whether the documentation is complete and legible and how well the physician communicates with the coder.

    If counseling the patient takes more than 50 percent of the total face-to-face E/M encounter, you can select the code based on the time element. For example, if the comprehensive history and examination and medical decision-making for an established patient take 15 minutes, and answering the patient's questions takes 40 minutes, 99215 (Office or other outpatient visit for the evaluation and management of an established patient ) would be correct because of the time involved in counseling.

    On the other hand, if the face-to-face encounter including counseling lasts only 25 minutes, this would be reported with 99214.

    For instance, a 45-year-old potential lung transplant recipient who is an established patient reports to the pulmonologist for a pretransplant examination. The patient has pulmonary hypertension. The physician orders tissue typing, chest x-ray, electrocardiogram, and hepatitis and HIV testing.

    The pulmonologist also provides E/M services, taking a detailed history and examination, which takes about 20 minutes. The pulmonologist also cousels the patient, discussing lifestyle changes after the transplant, what the patient can expect immediately after surgery, recovery time, risks associated with the surgery, and chances of rejection. The counseling takes 25 minutes.

    Because the pulmonologist performed a detailed history and physical examination, he may report a level-four established patient E/M visit (99214). "The physician also documented an additional 25 minutes of counseling," says Toni Revel, CPC, a coding expert and nurse practitioner based in Warrington, Pa. "Clearly, the amount of time documented is reasonable for all the topics covered by the physician."

    In this example, the pulmonologist spent more than half of the visit in counseling, which means he or she may report the level of care based on the total visit time 45 minutes resulting in 99215. In addition, "I would report V72.82 and 416.0 (Primary pulmonary hypertension)" for the diagnosis to support medical necessity, says Renee Brown, CPC, CHCO, CHCC, compliance officer for Southeastern Lung Care and The Sleep Disorders Centers of Southeastern Lung Care in Decatur, Ga.

    If the pulmonologist owns the x-ray and ECG equipment, he or she could report 71020 and 93000, Pohlig notes. But if the physician only interpreted the test results, he or she should bill 71020-26 and 93010.

    To justify coding according to the time element, the pulmonologist should document the visit's start and stop time and the counseling's start and stop time. Three additional elements must be covered to complete the documentation properly:

  • Who was in the session with the patient, i.e., family members, social counselor, etc.

  • What was discussed, i.e., additional tests, surgical risk, risk of immunosuppression, transplant options, what to expect after surgery, change in lifestyle, questions asked by the participants, etc.

  • Clinically relevant information as needed, such as the patient's response to the information provided in case future sessions are required for appropriate instruction and learning.

    Pulmonologists may assume that because of the patient's severe medical condition they do not need all of the documentation. But what the physician writes in the patient's chart must justify the code reported. It also has to make sense not only to the coder but to any reviewing body.

    And although the physician may believe that the coder understands how he or she works and what may be involved in the patient's visit, this is no excuse not to thoroughly document the encounter. Upon review by the U.S. Office of the Inspector General, sparse documentation may indicate upcoding and potential fraud.

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