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 [...]