Pulmonology Coding Alert

Please Medicare with surefire documentation

Pulmonology coders can get paid for E/M services and minor surgical procedures under Medicare's teaching physician (TP) rules if the medical documentation details the kind of supervision the attending physician provided, coding experts say.
 
The Medicare Carriers Manual (MCM), section 15016, defines residents as an intern or fellow who's enrolled in an accredited graduate medical education (GME) program, says Marti Geron, CPC, CMA, CM, coding and reimbursement manager the University of Texas Southwestern Medical Center at Dallas.
 
Experts offer three field-tested strategies for reporting E/M services using the teaching physician rules.

1. Report Office Consults Based on 'Key Portions'

You can report E/M codes if the TP personally furnishes the E/M service, such as an office consultation (99241-99245), without the resident present, said Jillian H. Kuruc, MHA, CPC, CCS-P, a clinical technical editor with Ingenix Health Intelligence in Binghamton, N.Y., during a session on the teaching physician rules at the Third Annual Coding, Billing and Compliance Essentials Conference in Orlando, Fla.
 
If the resident also performed this E/M service, your pulmonologist would have to duplicate the "critical and key portions" of the service that the resident performed to bill under this guideline, Kuruc tells Pulmonology Coding Alert. The TP should define - and be able to defend - those critical and key portions, she adds.
 
For example, a patient presents with wheezing (786.07). The TP identifies the physical examination as the visit's key portion. The resident evaluates the patient. Based on the findings, the resident diagnoses the patient with emphysema (492.x), recommends nebulizer treatments, and bills for 99213 (Office or other outpatient visit for the E/M of an established patient).
 
The TP also evaluates the patient, performs an exam, and discusses possible treatment options with the patient. Medicare requires that the attending physician only document that he or she performed the office visit's critical portion and that the physician directly cared for the patient.
 
Remember that the TP doesn't have to duplicate the resident's progress notes but should refer to the resident's notes and state that the TP reviewed the resident's medical documentation and agrees with the diagnosis, Geron says.
 
If the resident did not attend the pulmonologist's evaluation of the patient and also didn't perform a complete E/M service, your physician must bill and document the office visit as he would in a nonteaching setting, coding experts say.
 
In other words, to support a 99213 claim without the resident's supporting medical notes, the pulmonologist would have to document a detailed history, a detailed examination, and low-complexity decision-making.

2. Document Physician Presence for Critical Care

Medicare will also reimburse your pulmonologist for providing an E/M service jointly with the resident, Kuruc says. Suppose a patient has a severe anaphylactic reaction in the office. Your pulmonologist injects epinephrine (J0170, Injection, adrenalin, epinephrine, up to 1 ml ampule) into the patient, and the resident evaluates the patient's condition. The resident also monitors the patient's reaction to the epinephrine. Overall, the physician and the resident perform critical care services for 35 minutes.
 
In this case, your physician may be able to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), as long as the physician documents that he or she treated the patient jointly with the resident.
 
Also, the physician must prove that the critical care time doesn't include the injection. And your pulmonologist should show that he supervised the resident for the full 35 minutes of treatment, says Anthony M. Marinelli, MD, FCCP, chairman of the American Thoracic Society's Clinical Practice Committee.
 
When billing an E/M service performed jointly, the physician should note in the documentation that he supervised the resident during the history and exam.
 
Further, the TP should document the discussion with the resident concerning the epinephrine injection and critical care services.

3. Use Supervision Notes to Report Surgeries

When you report minor surgeries and endoscopic procedures, you should make sure the pulmonologist documents that he or she directly supervised the entire procedure, Kuruc says. That means Medicare requires the physician's presence in the room. For example, the physician can't view the surgery through a monitor in another room.
 
Suppose your pulmonologist supervised a resident during a transbronchial lung biopsy (31628, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial lung biopsy[s], single lobe) to diagnose extrinsic allergic alveolitis (495.x).
 
To get your pulmonologist paid for the 31628, the pulmonologist would have to remain in the surgery room from the insertion of the scope to the scope's removal.