Pulmonology Coding Alert

Pulmonologists are often called to the ED to evaluate patients. The provision of these services presents significant coding questions, according to Karen Bloxham, RN, BSN, specialty case manager, whose Milwaukee-based-company provides specialty insurance to businesses, associations, financial service organizations and individuals.

There are several ways to code that relate to this situation, and it can be confusing if you just look at the CPT manual, she says. A common problem is distinguishing between ED (99281-99285), critical care (99291-99292) and consultation codes (99241-99275.) Sometimes, it comes down to the language the physician used in the patient record, says Bloxham. He or she might have written, for example, Consulted with Dr. A re: patient in ED. The generality of this leads to confusion. The coder focuses on the word consulted and chooses one of the consultation codes rather than a more appropriate ED or critical care (CC) code.

When To Use ED Codes

These codes are used strictly to report E/M services delivered to a registered patient within the ED only, says Bloxham. CPT 2001 defines ED as an organized hospital-based facility for the provision of unscheduled episode services to patients who present for immediate medical attention. The facility must be available 24 hours a day. However, Section 15507c in the Medicare Carriers Manual (MCM) notes that the services provided in the ED do not have to constitute an emergency; it simply is a physician service for an unanticipated visit by the patient who is registered. More important, a non-ED physician can report an emergency code.

As an example, Bloxham describes a pulmonologist called to the ED regarding a 40-year-old male who has not seen the doctor in more than a year. The patient is having trouble breathing but is maintaining oxygen saturation rates. The physician examines him, decides on a course of treatment, prescribes the appropriate medications and instructs him to make an appointment to be seen in the office the following day. The likely code choices in this situation would be 99281-99285, the level depending on the three key components of history, examination and degree of medical decision-making.

When To Use Consultation Codes

Codes 99241-99275 are used if the physician is asked by the ED doctor to see a patient with pulmonary complications and the requirements of a consult are fulfilled:

The ED physicians request must be in writing and documented in the medical record;

The pulmonologist sees the patient; and

A written report detailing the treatment prescribed must be provided to the ED physician.

A typical situation might involve a young child. Since an ED physician may not be familiar with pediatric doses and treatments for juvenile asthma, for example, a pulmonologist may be called [...]