Pulmonology Coding Alert

File that E/M claim regardless of inconclusive diagnosis -- but make sure you document everything.

The level of evaluation and management (E/M) services provided during patient encounters for the pulmonology practice remains high. In fact, your physician's income could largely depend on the RVUs attached to the E/M codes. However, ample questions continue to surface about how to properly report these services.

Put your E/M coding skills to the test by examining the following Q&A.

Check Physicians' Matching Tax ID Before Billing 'New Patient'

Question 1: My clinic consists of multiple-specialty groups of physicians, and lately we have had a case of rejection for new patient visit from Medicare when the patient is indeed a "new patient" for a practice. The pulmonologist performed 31720 (Catheter aspiration [separate procedure]; nasotracheal) on the patient. Before this encounter, a different physician from another practice saw this patient (for the same treatment). This is what Medicare cites as the reason for the rejection. The two practices are totally different entities and do not share the patient database or records. Could this have anything to do with physician specialty codes and how they are matched to provider numbers?

Answer 1: Multi-specialty groups may share the same tax ID, but are enrolled with payers under different two-digit specialty codes. If the first physician belongs to a different specialty, you should appeal the decision as the payer is trying to avoid an overlapping care issue (when two providers are primarily caring for the same issue). If the other group within your tax ID is also enrolled as pulmonology, then you will be viewed as the "same group," even if you practice at different locations.

Consider Family Consultation Billable Under Certain Conditions

Question 2: My pulmonologist met with an elderly patient's family in the office to discuss treatment options and the patient's plan of care. The meeting took place without the presence of the patient. Can I still bill for an E/M service based on the time spent with the family? What about if a patient was present but cannot participate due to cognitive issues?

Answer 2: Most payers will only pay for an office visit if the patient is present.

CPT^® requires that the physician must meet face-to-face with the patient to report an established patient E/M visit (99211-99215). The only exception is if the physician must contact another individual (such as a spouse, parent, child, or other family member) to "secure background information to assist in diagnosis and treatment planning," according to the Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 70.1 (available at www.cms.hhs.gov/manuals/downloads/ncd103c1_Part1.pdf).

The manual further states, "In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder or comatose, the physician may contact relatives and close associates to secure background information to assist in diagnosis and treatment planning. When a physician contacts his patient's relatives or associates for this purpose, expenses of such interviews are properly chargeable as physician's services to the patient on whose behalf the information was secured. If the beneficiary is not an inpatient of a hospital, Part B reimbursement for such an interview is subject to the special limitation on payments for physicians' services in connection with mental, psychoneurotic, and personality disorders."

A physician may also have contacts with a patient's family and associates for purposes other than securing background information, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia. In some cases, the physician will provide counseling to members of the household. Family counseling services are covered only where the primary purpose of such counseling is the treatment of the patient's condition.

For example, two situations where family counseling services would be appropriate are as follows: (1) where there is a need to observe the patient's interaction with family members; and/or (2) where there is a need to assess the capability of and assist the family members in aiding in the management of the patient. "Counseling principally concerned with the effects of the patient's condition on the individual being interviewed would not be reimbursable as part of the physician's personal services to the patient. While to a limited degree, the counseling described in the second situation may be used to modify the behavior of the family members, such services nevertheless are covered because they relate primarily to the management of the patient's problems and not to the treatment of the family member's problems," explains Pohlig.

Key: Be sure to query your payer before submitting a claim for patient services when the patient is not present. Also, be sure your documentation precisely reflects the circumstances and discussion.

Report E/M Encounter Despite 'Likely' Diagnosis

Question 3: A new patient reported to our office complaining of wheezing and shortness of breath. The physician performed a level-four E/M, and then ordered spirometry with graphic record (we own the equipment, and the test was performed and interpreted in-house). Encounter notes describe "likely" emphysema, though the spirometry would not be expected to confirm it. How should I handle the diagnosis coding here? Should I wait for a definitive diagnosis before coding this claim?

Answer 3: Just because the encounter resulted in an inconclusive diagnosis, doesn't mean you cannot report -- and be paid for -- the physician's services. Just make sure the documentation supports the patient's presenting symptoms.

ICD-9-CM coding guidelines (Section I.B.6. and Section IV.E) state, "Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider."

What this means: If the doctor does not confirm emphysema, do not consider reporting any emphysema diagnoses. If the patient comes back for further testing that does reveal emphysema, then you can report an emphysema diagnosis. Instead, you'll probably look to 786.05 (Shortness of breath) and 786.07 (Wheezing).