Pulmonology Coding Alert

Pulmonologists usually assume care, negating a consult--but there are exceptions

For E/M services that start in one location and end in another, getting the payment your pulmonologist is ethically due hinges on reporting the correct code.

For instance, using an initial inpatient code when the visit counts as a consult could cost the pulmonologist $40 per encounter--reporting 99222 (3.40 nonfacility relative value units) instead of 99254 (4.46 nonfacility RVUs) results in a loss of $40.17 using the 2007 National Medicare Physician Fee Schedule. But this coding when the reverse is true could trigger refund requests.

See if your claims would withstand an audit by testing your hand with the following scenarios, then read our experts' answers.

Use 1 Code When In-Office Becomes Admit

When coding for office visits and admission services, you should report only one E/M service per calendar day, says Mary Mulholland, MHA, RN, CPC, senior coding and education specialist for the department of medicine at the Hospital of the University of Pennsylvania.

Example: A pulmonologist diagnoses a patient with pulmonary embolic disease (such as 415.19, Pulmonary embolism and infarction; other) during an in-office visit and then admits the patient to the hospital. Inpatient records show the pulmonologist saw the inpatient the same day as the office visit.

Do this: You should report only the initial hospital care with 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...), says Rhonda Buckholtz, CPC, practice administrator at Wolf Creek Medical Associates in Grove City, Pa. But "you can use the documentation from both visits to report your level of service," she adds. For instance, if the pulmonologist makes a quick note on the office visit and then starts the inpatient note for the admission, you would combine the documentation to select the appropriate level of initial hospital care code.

Important reminder: To report the initial hospital service (99221-99223), the physician must provide a face-to-face encounter in the hospital setting.
 
"Having only a face-to-face encounter in the office does not allow the physician to report the initial hospital visit," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. In these cases, the pulmonologist should instead report an office visit (99201-99215, Office or other outpatient visit ...).

Separately Code for Admit on Day 2

Don't assume that every time an office visit results in a hospital admission that you'll bill only one E/M service. When a pulmonologist admits a patient to the hospital from the office, he may not necessarily see the patient on the same day, Mulholland says. The attending physician may see the patient and complete the admission service the next day.

Because the attending has 24 hours to see the patient in the hospital, and you don't bill the admission until the first face-to-face occurs between the patient and the attending pulmonologist, you can ethically maximize reimbursement by reporting an E/M service for each day, Mulholland says. Report the office visit (99201-99215) on day 1 and the initial hospital care code (99221-99223) on day 2. "Choose the level of service code based on the amount of information documented in the medical record," she says.

Report 9922x When Patient Is Admitted

Get ready to mark an initial hospital care code anytime a patient comes into your pulmonologist's care via the emergency department (ED). "ED physicians do not admit or follow patients in the inpatient setting," Buckholtz says. Because the pulmonologist would not be reporting back to the ED physician, the pulmonologist's patient encounters do not qualify as consultations.

Example: An ED physician sees a patient with acute shortness of breath, chest pain, dizziness and coughing up blood, and diagnoses him with a pulmonary embolism, which requires admission to the medical intensive care unit. Because the pulmonologist is responsible for the patient's admission and ongoing care, you should report the service as initial hospital care, Mulholland says.

Link 9922x to the PE diagnosis (such as 415.11, Iatrogenic pulmonary embolism and infarction) and any additional symptoms, such as shortness of breath (786.05), chest pain (786.50), dizziness (780.4) or coughing up blood (786.3, Hemoptysis).

Exception: If the ED physician takes the pulmonologist's advice and then discharges the patient, use a consultation code if the documentation supports the service's requirements. The ED physician might ask for the pulmonologist's opinion on how severe a patient's embolism is or for questions on anticoagulation therapy, Mulholland says. If the ED physician only asks for the pulmonologist's opinion, takes his advice and then discharges the patient, report an outpatient consultation (99241-99245, Office consultation for a new or established patient ...). The ED is considered an outpatient location (place of service 23).

Don't Be the 2nd Hospital Care Reporter

Let another physician's use of initial hospital care codes be your heads-up to coding an inpatient consultation service (99251-99255, Inpatient consultation for a new or established patient ...). "Only one physician can report an initial hospital visit," Mulholland says. You may report additional same-day services as consultations, as long as the service meets a consultation's requirements.

Example: An endocrinologist admits a diabetic patient and requests a pulmonology evaluation. You should count the pulmonologist's first visit in which the endocrinologist requests the pulmonologist's opinion as a consult, Mulholland says. If the pulmonologist then provides ongoing care to the patient for the pulmonary condition, you should report each service following the consultation as subsequent hospital care days with 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...).