Pulmonology Coding Alert

Question: A patient with chronic obstructive pulmonary disease (COPD) is scheduled for a lobectomy. The thoracic surgeon requests the patient's pulmonologist to provide the preoperative risk assessment. The pulmonologist uses ICD-9 codes for "Pre-op--V72.82" and "COPD without exacerbation--491.20."

After the patient undergoes the lobectomy, the surgeon requests a consult for "post-op management" on the patient's chart. The pulmonologist provides this the next day along with aggressive pulmonary toilet, broncho-dilator and steroids.

May I report both services as consultations?


Washington Subscriber

Answer: Although the preoperative risk assessment probably qualifies as a consultation, the postoperative management is less likely to count as a consultation. Here's why:

The pulmonologist performed the preoperative exam for surgical clearance based on a surgeon's request--a scenario that meets the first criteria for a consultation (99241-99245, Office consultation for a new or established patient ...). Before using 99241-99245, make sure documentation supports this service's other two requirements:

• the pulmonologist renders her opinion on the patient's COPD and ability to withstand the lobectomy and anesthesia

• she sends a report to the thoracic surgeon detailing her findings. 
 
When the E/M service does not meet the above consultation requirements, you should instead report an established patient office visit (99212-99215, Office or other outpatient visit ...).

Use 99241-99245 or 99212-99215 with the ICD-9 codes the pulmonologist listed: V72.82 (Pre-operative respiratory examination) and 491.20 (Obstructive chronic bronchitis; without exacerbation).

Using a consultation code for postoperative management seems more dubious. If the thoracic surgeon is truly requesting the pulmonologist's opinion on the patient's postoperative condition and is still coordinating the patient's inpatient care, the visit may qualify for 99251-99255 (Inpatient consultation for a new or established patient ...). Key: The shared chart note must indicate the pulmonologist's opinion.

Problem: An order of "Postoperative management" seems to indicate the pulmonologist will take care of the patient. If he is indeed assuming postoperative inpatient care after providing a preoperative assessment, you should instead bill subsequent hospital care codes (99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) with the problem you are caring for, such as acute respiratory failure (518.81) and COPD exacerbation (491.21, ... with [acute] exacerbation).