Pulmonology Coding Alert

Question: Should we consider time as a factor when billing for educational/counseling services that someone other than our pulmonologist provides (such as a registered nurse or physician assistant)?

California Subscriber

Answer: You should consider time as a factor depending on the location of the service, as well as the provider of the service.
 
When someone other than the pulmonologist provides services in an office setting, you should refer to "incident-to" guidelines. Incident-to service guidelines allow the pulmonologist's staff to provide services to an established patient as an integral and incidental part of the plan of care established by the pulmonologist.

Note: In incident-to services, the pulmonologist reports the services under his name as if he provided the services.

Example: A physician assistant may administer a stress test in your pulmonology practice. The pulmonologist must be present in the office suite (without the need to be present in the room with the patient) during the time the PA delivers incident-to services.

In the office setting, only the pulmonologist can consider his time as a factor in selecting the appropriate code for reporting the incident-to visit (such as 99211-99215). Other than the pulmonologist, you should not consider anyone else's time in choosing the most appropriate code to report when providing counseling and/or coordination of care in the office.

Exception: If a clinician other than the pulmonologist provides a patient service in certain facility settings (such as ED, inpatient hospital or outpatient hospital), "shared/ split billing" rules apply.

You should consider time as a factor in choosing the most appropriate code if the clinician is Medicare-enrolled (that is, he must have a Medicare UPIN; such as a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse). 
You should consider the services provided by both the pulmonologist and the nonphysician practitioner (NPP) as a cumulative effort.
 
If more than 50 percent of the total service involves counseling/coordination of care, you can bill the service using only the amount of time when selecting the visit level and corresponding code.

Don't miss: You must have documentation of the counseling time as well as the total visit time in the medical record (that is, 15 of 25 minutes spent counseling re: ...). 

You should select the visit level based on the total visit time (such as, 99214 = 25 minutes). In the outpatient area, you should count only the pulmonologist's and/or NPP's time spent face-to-face with the patient.

But in the inpatient setting, you should count the time spent with the patient as well as on the "unit/floor" involved in caring for the patient toward the total time.