Pulmonology Coding Alert

If you answered all 3 questions correctly, youre a Part B ace.

Now that youve tested yourself with the questions on the previous page, find out if your Part B skills are up to speed.

Do Different Specialty Practices Count?

Answer 1: The answer depends on whether the two pulmonology practices share a tax ID number, says Barbara J. Cobuzzi, MBA, CPC,CPC-H, CPCP, CENTC, CHCC, senior coder and auditor for The Coding Network and president of CRN Healthcare Solutions in Tinton Falls, N.J.

CMS specifically states that the patient is a new patient when seen under the same tax ID number by a doctor of a new specialty, not a doctor who does not share a chart, Cobuzzi says. As a matter of fact, the pulmonology group may be sharing the chart with a different specialty. That is not the metric.

If the physicians of the same specialty do not share the same tax ID number, then they may have a case worth appealing, Cobuzzi says. They need to talk to their MAC (Medicare Administrative Contractor), Cobuzzi advises.

This could all be an electronic issue resulting from the conversion from local Medicare Carriers to regional MACs and a glitch in the system.

CanYou Report Family Visits?

Answer 2: Medicare will only pay for an office visit if the patient is present, says Atlanta-based coding consultant Jay Neal.

Medicare requirements specify 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The manual further states, In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder or comatose, the physician may contact relatives and close associates to secure background information to assist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 patients relatives or associates for this purpose, expenses of such interviews are properly chargeable as physicians 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.

Key: The patient must be unable to provide the information himself. In this case, you may be able to report a low-level visit, but expect Medicare to reject the claim unless your documentation is especially clear as to the reason that contact with the family member was absolutely necessary.

Additionally, the manual states, a physician may also have contacts with a patients family and associates for purposes other than securing background information,

such as when the physician provides counseling to members of the household. Family counseling services are covered only where the primary purpose of such counseling is the treatment of the patients condition, relates Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania.

Example: Two situations in which family counseling services would be appropriate are as follows: (1) when there is a need to observe the patients interaction with family members; and/or (2) when there is a need to assess the capability of and assist the family members in aiding in the patients management. Counseling that you principally focus on the effects of the patients condition on the family member, however, would not be reimbursable as part of the physicians personal services to the patient. While, to a limited degree, you may use the counseling described in the second situation to modify the family members behavior, such services nevertheless are covered because they relate primarily to the management of the patients problems and not to the treatment of the family members problems, offers Pohlig.

Is Likely A Diagnosis?

Answer 3: Just because the encounter resulted in an inconclusive diagnosis, that does not mean you cannot report -- and be paid for -- the physicians services. Just make sure the documentation supports the patients 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.

Translation: If the pulmonologist 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, youll probably look to 786.05 (Shortness of breath) and 786.07 (Wheezing).