Pulmonology Coding Alert

The pulmonologist's order may count for more than you think

With advice from CMS and our coding experts, consider each step your pulmonologist takes from beginning to end to report the highest and most appropriate code level every time.

Use the three questions about E/M guidelines that we posed to a CMS policy official who spoke with us on the condition of anonymity. Here's what we learned:

Diagnostics Impact Complexity Level

1. Question: Suppose a pulmonologist orders a diagnostic test, such as a spirometry, but the patient refuses to undergo the test. Should the pulmonologist still get credit for the order when determining the level of complexity associated with the encounter?

CMS response: You should factor the pulmon-ologist's order into the medical decision-making or care/treatment plan. Be sure the pulmonologist documents the order, the patient's refusal, and why he did so.

What you should know: Your pulmonologist's decision to order a diagnostic test can impact each of the complexity section's three elements (medical decision-making), coding experts say.

Pulmonologists frequently recommend testing or treatment options that the patient declines for various reasons (for example, financial concerns or reservations about risks), says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy and Critical Care at Emory University School of Medicine in Atlanta.

Factoring in the pulmonologist's order makes sense. Rationale: If the pulmonologist "went through the medical decision-making process to determine that the patient needed a particular test, even though the patient didn't follow through, the physician ... should receive credit for that, provided there is documentation of that thought process," says Sherry Wilkerson, RHIT, CCS, CCS-P, manager of coding and compliance for CHAN Healthcare Auditors in St. Louis.

Example: A patient presents to your pulmonologist's office for wheezing (786.07, Wheezing). The pulmon-ologist reviews the patient's history and examines the patient, concentrating on the lungs, upper airways, eyes, ears, nose and throat.

The pulmonologist cannot evaluate the airways from the examination alone, so he performs pulse oximetry and uses a spirometer to measure pulmonary function. He administers a bronchodilator to the patient, followed by another pulse oximetry measurement and spirometry. He then compares the before and after readings to assess the bronchodilator's success.

Based on the test results, the pulmonologist decides that the best course-of-care plan for this patient is nebulizer treatments. The patient's mother refuses to follow the pulmonologist's advice and says she will seek a second opinion.

Don't miss: Your pulmonologist should note in the chart this refusal and the specific reason the patient's family refused treatment, not only as part of the medical decision-making, coding experts say.

2. Question: A patient presents with shortness of breath. The pulmonologist documents that "the patient's chief complaint is shortness of breath, which is not exacerbated with any specific activity and has no reported associated symptoms." Should the pulmonologist receive credit for documenting the HPI elements of "modifying factors" and "associated signs or symptoms," even though he reported that no activity exacerbates the condition and no associated signs or symptoms exist?

CMS response: The pulmonologist should absolutely receive credit. What you've provided is valuable information, which the pulmonologist should document.

Quick tip: Don't let the pulmonologist document that the patient's HPI is negative. Instead, if the patient has no exacerbating activities or associated symptoms, as in the above example, the physician should put that in the documentation.

For example, in the documentation, the pulmonologist should write, "The patient relays that her problems are not related to time of day, she relays no aggravating or alleviating factors, and there are no associated symptoms," experts say.

The bottom line: With this simple sentence, the pulmonologist would receive credit for three HPI elements, which corresponds to a brief HPI.

When you also add in the documentation "an anatomic description of where the problem is (which may be possible for a majority of the presenting problems), you would firmly establish an extended level of HPI, which requires four documented elements," experts say.  

Under the 1995 set of documentation guidelines, an extended HPI is required for level-four and -five established patient visits (99214-99215) and any new patient visits or consultations above level two (99203-99205, 99243-99245, 99253-99255), Plummer says. 

"This distinction pretty much eliminates any advantage in the history component that the 1997 guidelines brought to the table for virtually all physicians," experts say.   

3. Question: The Marshfield Clinic's audit tool awards two credits for independent visualization of an image, tracing or specimen itself (not simply review of a report). The tool also awards one credit for ordering a diagnostic test. If the pulmonologist ordered a test (such as a pulmonary function test), and he personally reviewed the results on the same day, would he be awarded credit for both the order (1 credit) and the personal review (2 credits)?

CMS response: Yes. The order and personal review are two separate activities. If your pulmonologist orders the pulmonary function test (PFT), he might not get to review it. If he does review it or look at it in a scope and make judgments, then documenting this activity should allow your pulmonologist to have credit for both ordering and reviewing it (not just reading a report).

What this means: "This clarification is huge for physicians who personally review their own diagnostic testing," experts say. However, if you are billing for the "interpretation and review" of the diagnostic tests you perform, you cannot receive credit in MDM for reviewing the test. 

This is a requirement of billing for the test and would be considered "double-dipping" if you were also to receive E/M credit for this. E/M credit for ordering is still allowable when billing for interpretations of testing.

Let's break it down: You should understand that, when it comes to the audit tool's complexity section, you only need four points in the data section to achieve a "high" level of medical decision-making, assuming that at least one of the other medical decision-making categories (diagnoses/treatment options or table of risk) also supports this level of complexity. 

Note: Turn to "Use This Handy Chart to Nail Down the Elements of 99213 and 99214" in this issue to learn the basic differences between two of your most reported E/M codes.