Pulmonology Coding Alert

If the results of the recent Comparative Billing Report revealing pulmonologists’ subsequent hospital care codes surprised you, perhaps you could use a coding refresher. In particular, the report revealed that pulmonologists had the highest rate among specialists of billing 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: detailed interval history; A detailed examination; Medical decision making of high complexity … 35 minutes are spent at the bedside and on the patient’s hospital floor or unit).

Because 99233 is the highest level of subsequent hospital care, documentation requires two of these three criteria: a detailed history, detailed exam, and/or high-complexity medical decision-making (MDM).

Of the three E/M components — history, exam, and medical decision-making — you must fully document two components meeting the level of the E/M code selected to justify use of each subsequent care code. If there is little or no documentation, then you need to change the code.

Typically, pulmonologists document the exam and medical decision-making components to fulfill CPT^®’s E/M requirement. If your physician performs and documents high-complexity medical decision-making along with a detailed exam, this supports a 99233. But if the documentation falls short on both of the other two elements and doesn’t justify the level of care using time as the key component, even if the doctor says he did more than what’s on paper, then it’s an appropriate time to go over the essentials of thorough documentation with all of the practitioners in your office.

Tip: You can also report 99233 based on time if you meet the documentation requirements.  CPT^® assigns a 35-minute time threshold to this code. Although many coders think of time-based E/M coding only as an outpatient strategy, it’s perfectly acceptable to use time as your overarching code selection criteria in the inpatient setting, if you meet the guidelines.

Ensure that the following three factors are documented in the hospital record if you select 99233 based on time: The total visit time at the bedside and on the floor directed toward the patient’s care  (which should be at least 35 minutes), the time spent counseling/coordinating care, and a description or summary of the counseling/coordination of care provided.

For instance, “Saw the patient for 35 minutes face-to-face; 20 minutes of that visit was spent counseling the patient and her daughter about her COPD diagnosis, potential treatment options and prognosis; answered multiple questions and provided them with educational information.”

Best Practice Guideline: In order to select time, more than 50 percent of the total visit time must be spent counseling/coordinating care. Otherwise, you must rely on the key components for visit level selection.