Pulmonology Coding Alert

Similar to coding for new patient visits (see September 2001 Pulmonology Coding Alert), coding for established patients can be challenging. While 99211-99215 outline the requirements for these office and outpatient visits, ensuring that a pulmonology practice realizes fair and accurate reimbursement can be more involved than is apparent.
 
As with new patient codes, each established patient code specifies an amount of time spent with a patient and/or family. However, as Walter ODonohue, MD, FCCP, FACP, chairman of the CPT committee of the American College of Chest Physicians (ACCP) and a representative to the AMA CPT advisory committee for ACCP, explains, The history, examination and level of decision-making are the key components in determining the level of the code used. Time becomes the primary factor only if counseling or coordination of care with other professionals is involved. 
 
Carol Pohlig, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania, explains the difficulty in coding these established patient visits. Practices tend to undercode these visits because the health problems and medical history are familiar, she says. Thus, even though the amount of work and the level of decision-making are actually quite complex, the physician may inadvertently code at a level lower than warranted because the medical decision occurs in a quicker manner.
 
She adds that Physicians do not realize they are not audited based on the time it took to make a medical decision. They are audited based on their thought processes and how well they document how they arrived at a medical decision. Documentation is the most important factor. Physicians need to be careful to include all of the systems reviewed and all the procedures performed for complete reimbursement.

The First Level
 
 
The simplest visit is coded 99211 (office or other outpatient visit), for the E/M of an established patient, which may or may not require the presence of a physician. Usually the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.
 
This code encompasses a visit for a limited problem that may not need the services of a physician. For example, a 63-year-old patient with chronic obstructive pulmonary disease (COPD) who takes various medicines and uses several treatments becomes confused about the amount and frequency of each. 
 
Needing guidance in comprehending and adhering to his regime, he presents at the pulmonologists office and is educated by the nurse in the proper way to take the medicine. In this example, the level of care suggested by this code is minimal, both in the time spent with the patient and the complexity of the service performed.
 
The Second Level  
The next level of care is covered by 99212 (office or other outpatient visit), for the [...]