Pulmonology Coding Alert

Your pay hinges on differentiating pulmonologists role from allergists.

Allergy season often presents the dilemma of when and how both an allergist and pulmonologist can report services for the same patient. Read on for tips to optimize your coding when this situation arises.

Familiarize Yourself With Medicares Slant

Medicare reimburses for concurrent care when physicians provide services more extensive than consultations and when both physicians play an active role in the patients ongoing care.

To get paid in a concurrent care scenario, you must be able to justify having two related specialties on board, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Follow these two rules of thumb to help ensure payment:

1) Diagnosis: Verify that the diagnosis or diagnoses support the medical necessity of involving two specialists in the patients care, and

2) Unique services: Clarify the care both doctors provided to prevent any misunderstanding that the pulmonologist or allergist alone assumed total care for all presenting conditions.

Challenge: The latter criteria means its harder to prove to Medicare that concurrent care is reasonable and necessary if its provided by physicians of the same specialty or by physicians with a similar knowledge base, such as pulmonologists and allergists. There are, however, two main ways to make your case:

Highlight Exacerbations as Key to Diagnosis Criteria

While such is the ideal, patients who require concurrent care dont always have distinct underlying conditions.

Example: If an allergist and your pulmonologist both evaluate a patient for the same underlying condition -- for instance, extrinsic asthma (493.0x) - youll have to work to convince the payer that the patients condition merited two treating physicians.

What to do: Remember that an exacerbation, such as an episode of acute bronchitis (493.22), serves as a reasonable justification for the pulmonologist to see a patient whos also seeing an allergist for asthma management, offers Pohlig. In this case, the pulmonologist is better able to treat the exacerbation by administering a bronchodilator (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device]), for instance.

Tip: If both physicians see the patient on the same day and/or in the same office area, then they must bill for services using different ICD-9 codes, says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. The pulmonologist could code for the extrinsic asthma and the allergist for rhinosinusitis (473.9, Unspecified sinusitis [chronic]) if the pulmonologist wasnt managing that problem as well, or allergic urticaria (708.0), Plummer explains.

Ensure Specialty Services Stand Out

Carriers will not reimburse concurrent care services if the services of one physician duplicate another.

Also, if a second physician does not demonstrate unique qualifications to treat the condition, Medicare will pay only for the first physicians services, states the article A Refresher on Medicare and Concurrent Care published in the Journal of Family Practice Management.

Some physicians prefer to follow up with their patients to see if they are improving based upon the implemented management options, says Pohlig. In these cases, focus on documenting the need for the pulmonologist to stay on board once he determines that an allergist should participate in care.

When the pulmonologist continues to manage a patients asthma and the allergist is attending to the allergic manifestations, each physician needs to take care in documenting the reason he saw the patient throughout the course of concurrent care, what the physical and history revealed, and what the treatment program was, Plummer advises.

When the pulmonologist schedules a follow-up visit after referring the patient to the allergist, you must demonstrate that the pulmonologists involvement is reasonable and necessary. The pulmonologists role, for instance, would be to perform an evaluation of the patients underlying condition (extrinsic asthma) to determine whether his overall lung function has improved, says Pohlig. The E/M code the pulmonologist reports for the visit depends on the complexity of decision making (99213 [low complexity] vs. 99214 [moderate complexity] or 99215 [high complexity]) as well as other key components, notes Plummer.

Wage Appeals with Solid Documentation

Ensuring complete documentation is, of course, your best line of defense against concurrent care denials.

Focus on documenting details of the pulmonologyspecific approach or patient management that is different from the allergists care plan, advises Pohlig, and remember these handy concurrent care justifications:

" Exacerbations

" Evaluation of an underlying condition to determine whether its improving

" Evaluation of medications effectiveness until allergy shots start working

" Evaluation of the pulmonology-specific management options.

If you have access to the allergists notes, they can certainly help you demonstrate two different evaluations should denials arise and appeals ensue, says Pohlig.

Sum up: While the hassle factor might be a little greater with concurrent care claims, you can prevail if you meet the criteria because Medicare does cover them, concludes the JFPM article.