Pulmonology Coding Alert

Check your billing records for tax IDs, past visits

Myth: If your pulmonologist hasn't seen a patient in your office in the past three years, you can always bill a new patient visit.

Reality: Not necessarily. Even if your pulmonologist saw the patient in another location within the past three years, it may not be a new visit. Further, if another doctor with the same specialty in your group saw the patient within three years, you can't bill for a new patient visit.

Bill Separate Specialties as New

Example #1: A group of pulmonologists has a hospitalist physician who shares a tax ID number with them, says Nancy Giacomozzi, office manager with P.K. Administrative Services in Lakewood, Colo. If the hospitalist sees the patient first (99221-99236, Hospital inpatient services) and then the patient visits the pulmonologist in their office, it may count as a new patient visit.

Section 30.6.5 of the Medicare Claims Processing Manual states, "Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group." Because hospitalists are board-certified in internal medicine and not pulmonary/critical care medicine, they are considered "separate specialties," says Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "Additionally, the focus of the hospitalist's care and the pulmonologist's care is different." Physicians with different specialty distinctions who practice in large "multi-specialty" provider groups may treat patients as if they were separate groups despite reporting under a single tax ID.

Caution: Check your billing records carefully to make sure no other doctors with the same specialty and tax ID number have seen the patient within three years before billing a new visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...), Giacomozzi says.

New resource: Luckily the AMA has included a handy flowchart of new-versus-established along with CPT 2007. It clarifies that only face-to-face services count in determining new or established status, so if your doctor only interpreted test results for a patient in the past, you can still claim that patient as a new patient. Also, the location in which a doctor saw the patient doesn't matter.

Count Cross-Town Visits as Seeing Patient

Example #2: A group practice maintains two offices on separate sides of town. A patient sees pulmonologist "A" for a complaint at location "Y." Six months later, the same patient sees pulmonologist "B," in the same group practice, for a new complaint at location "Z." This would still count as an established patient visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...).

Consults: Also, some specialists seem to believe that whenever they see an established patient with a new problem, they should at least be able to bill a consult. But such a visit only counts as a consult if the physician is not providing ongoing care to the patient for other issues, and if another physician actually requested the specialist's opinion, says Deborah Churchill with Churchill Consulting in Killingworth, Ct.

The only exception to this rule is preoperative consultations, in which the pulmonologist provides perioperative risk assessment for his established patient at the request of the surgeon.