Pulmonology Coding Alert

Question: We are billing an office visit for a patient with COPD and asthma, coded properly as 99215. The provider is also billing 99402, which I am not in agreement with. The visit was strictly to manage the patient’s medications, evaluate progress, and discuss whether he’s a candidate for lung volume reduction surgery. He also talked to the patient about risk factors for lung cancer and his family history of this and other conditions. I know it’s allowable to bill both 99215 and 99402 with a modifier, but I am stuck on the decision of whether to code 99402 in this situation as well.

Codify Subscriber

Answer: The answer to this question really depends on what your provider discussed with the patient during the counseling session and what is documented in the record. If the counseling in the E/M session is focused on the patient’s risk for lung cancer and the pulmonologist reevaluated the patient’s condition, adjusted the patient’s medication, and provided a medication refill, then you should usually only code 99215 (Office or other outpatient visit for the evaluation and management of an established patient … Typically, 40 minutes are spent face-to-face with the patient and/or family).

However, if the physician spent at least 15 minutes just in counseling concerning the lung cancer risk factors as opposed to the COPD — in other words, the counseling is for a totally different issue — then you might consider also reporting 99402 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes).

And, because you are billing two E/M codes, you would append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the 99402 counseling code.

Coding caution: If your pulmonologist coded by time on the 99215, it’s going to be difficult to separate the two distinct timed services, so if this is the case, make sure you mark the start and stop times of the separate services in the patient record.