Pulmonology Coding Alert

Pulmonology practices can optimize reimbursement for evaluation and management (E/M) services by documenting E/M codes based on time if the physicians counseling time with the patient comprises 50 percent or more of the entire visit.

History, examination and medical decision making are considered the key components to solid documentation for time consuming E/M services (99201-99215), says Alan Ertle, MD, MPH, of The Corvallis Clinic, P.C. in Corvallis, Ore. The basic format for E/M services recognizes seven components, six of which are used in defining the levels of E/M services, Ertle explains. The CPT lists these components as:

History
Examination
Medical decision making
Counseling
Coordination of care
Nature of presenting problem and
Time.

For an established patient, two of these three components must meet or exceed the stated requirements to qualify for a particular level of E/M services, he says. Counseling, coordination of care and nature of presenting problem are considered contributory factors in most encounters. These services are not required to be provided at every patient encounter, he explains. The level of E/M services for a new patient requires that three components be met:
Inpatient admission
Consultation and
Emergency department service

Since 1995, HCFA [the Health Care Financing Administration] has required significantly improved documentation to justify the various levels, Ertle explains. This means if you do a level 5 established office or other outpatient visit (99215), significantly more documentation regarding history, review of systems, social and family history, organ systems examined, lab and other tests reviewed and medical-decision making must be included.

The E/M codes cover a host of other things besides annual physical visits, says Nancy DeMarco Lamare, CPC, CCS-P, with Central Maine Clinical Associates in Lewiston, Maine.

What Constitutes Counseling?

The CPT defines counseling as a discussion with a patient and/or family concerning one or more of the following areas:

Diagnostic results, impressions, and/or recommended diagnostic studies

rognosis

Risks and benefits of management (treatment options)

Instructions for management (treatment and/or follow-up)


Importance of compliance with chosen management(treatment) options
Risk factor reduction and
Patient and family education

If an established patient comes in for a specific ailment, say for a normal x-ray for pulmonary (793.1), suggests Lamare, and he begins to ask questions, the physician can immediately discount the history exam and medical decision-making and go directly to time.

The CPT introduction states that time may be the key or controlling factor to qualify for a particular level of E/M services. This raises the level for which the visit can be billed. A 99211 visit becomes a 99213 when the physician, after five minutes of conducting the history, foregoes the physical and medical decision-making portion and spends 10 minutes counseling the patient, says Lamare. The 15 minutes is [...]