Pulmonology Coding Alert

Question: Our pulmonologist saw an initial inpatient, but couldn't get all information from him. He performed a comprehensive exam and complex medical decision making based on the patient's current condition. Can we give credit for a comprehensive history even though he couldn't obtain a comprehensive ROS (review of systems) due to the patient being mentally confused?

Florida Subscriber

Answer: There is no written rule that you can automatically give credit for a comprehensive level when all or part (e.g., ROS) of a patient's history is unobtainable. In general, you can only give credit for the level of history that is documented. The viewpoint might be payer specific, so check with your local payer.

Tip: However, most Medicare contractors allow providers to count history toward the level of E/M service you bill if you are unable to obtain it directly from the patient. But you must document that you made an effort to obtain information about the patient from other sources.

Action: The "Documentation Guidelines for E/M Services" states, "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstances which precludes obtaining a history." Accordingly, verify that your pulmonologist clearly documents the reason the patient is unable to provide a history, and document his efforts to obtain the patient's history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information from the records to document some of the history components (past medical, family, social).

Note:If the E/M code you wish to bill requires only two of three E/M components, you can use the physical examination and medical decision making to determine the level of service.

In your case, the pulmonologist was performing an initial inpatient visit, which requires that all three components (history, exam, and medical decision making) be met, including at least a detailed history. If you have indicated that you sought information from all available sources, and your service documentation supports at least a detailed history, you may report an initial hospital care code (99221-99223) based on that history and the documented physical examination and medical decision making. In cases where the payers disallow history credit when unobtainable, and the lack of history precludes you from reporting an initial hospital care code, then you may want to consider reporting a subsequent hospital care code, which only requires two of three key components, based on the examination and medical decision making.