Pulmonology Coding Alert

Question: A new patient who is unable to communicate clearly and to explain her medical problems came in to see the pulmonologist. Her condition prevented the pulmonologist from obtaining a complete history of present illness (HPI) and ROS from her. Therefore, the pulmonologist could not develop a definite assessment or plan for her treatment. He called the patient’s two previous physicians to discuss her medical problems. Including face-to-face patient time (45 minutes) and telephone calls (45 minutes) to other providers, the pulmonologist spent a total of 90 minutes on this patient on the same day. How should I charge for this scenario? Which E/M codes and modifiers should I use to justify the extra time that the pulmonologist spent on the phone with other physicians on this patient’s behalf?

Codify Subscriber

Answer: You should bill the scenario based on the appropriate level of E/M service (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient).

If you want to bill based on time, the physician must spend more than 50 percent of the total face-to-face time counseling and/or coordinating care with the patient. If your physician’s encounter does not meet this requirement, you cannot bill based on time.

Extra: You also cannot bill based on time if the physician states that a communication barrier extended the face-to-face time with the patient. Communication barriers do not meet the counseling/coordinating care criteria.

The physician may document the excessive effort of trying to get an appropriate history with the reason for excessive effort and a reason for why he was unable to obtain the full history. The physician may receive credit for the “unobtainable” history.

If the physician reports service time when the patient is not physically present, you cannot report this time to most payers.

Payers consider extra time, as noted in the example above, to be part of the pre- and postservice work associated with the payment for the evaluation and management service. If you submit a charge for this extra time to a payer that does not cover the service, the carrier may hold the patient responsible for the fee.