Pulmonology Coding Alert

Question: Our pulmonologist was called for an emergency consultation. Can we bill for the consult under 99221-99223? If all components are not met do we have to bill the lowest level? For example, Review of Systems (ROS) could not obtain Past, Family and Social History (PFSH) but has seven elements for exam. 

Washington Subscriber

Answer: Yes, you can bill the consult under 99221-99223 if the payer has disallowed payments for consult codes (99251-99255) and permits the use of these codesby consultants (as Medicare does). 

However, if the minimum requirements of initial hospital care are not met, then you cannot report 99221(Initial hospital care, per day, for the evaluation and management of a patient….), in spite of the encounter being the initial one, as you should consider the code as the highest level. 

In cases such as yours, a subsequent hospital care service is reported, based on medical decision making (MDM) and history or MDM and exam (the highest combination). Keep in mind that if the physician is unable to obtain portions of the history (ROS, PFSH) due to the patient’s condition, he/she must attempt to obtain from the chart, the staff, family (if available), etc. The provider documents what is obtained and indicates what cannot be obtained along with the reason. He/she may receive credit for the attempt. 

However, in this case, the exam is still deficient to be able to report 99221. When selecting the appropriate subsequent hospital care service, let the MDM serve as your guide. You can report 99233 if your pulmonologist documents high complexity MDM (along with a detailed history or exam).Select 99232 if the MDM is only moderate, and you have an EPF history or exam.Code 99231 only requires low complexity and a PF history or exam.