Pulmonology Coding Alert

Question: As a pulmonologist and sleep specialist, I spend a lot of time discussing management, CT scan results, sleep studies, and management of sleep disorders. Most of these are time-based. How do we do that best?

Wisconsin Subscriber

Answer: When a physician spends more than 50 percent of total visit time (face-to-face in the outpatient setting, or on the inpatient unit/floor after a face-to-face patient encounter), he can bill based on time instead of the key components (history, exam, and medical decision making). The patient should be involved in the discussion. Document the details of the discussion as well as the time. For example, "25 minutes spent with the patient discussing CT scan results, sleep studies, and management of sleep disorders." Fill in the remaining details, as appropriate. Report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-toface with the patient and/or family).