Pulmonology Coding Alert

Your pulmonologist usually provides pre-, post-op consults.

Coders who don't want their consult claims cancelled should take a second and check out these expert opinions on when to code a consult -- and when to choose another reporting option.

"A consultation is basically a request for opinion or advice, because the requestor does not have expert knowledge in that area," explains Denae Merrill, CPC-E/M, owner of Merrill Medical Management in Michigan.

But it can be a bear sticking to all of the consult reporting rules, because your coding will vary based on location and service level. Read on for more information on coding -- and documenting -- your consultations correctly each time.

If a physician is treating a patient and needs to ask for your pulmonologist's input on treating that patient for a certain condition, you should consider it a consultation. When she provides the consultation in an office setting, you select one code from 99241-99245 (Office consultation for a new or established patient ...). Your code choice depends on the elements of history, examination, and medical decision making that your physician documents during the visit.

Some guidelines require a physician or qualified nonphysician practitioner (NPP) to make the request for a consult, but others state that the request can be from a physician or other appropriate source. You must also be wary of state scope of practice issues before your NPP files a request for consultation. Remember: Medicare limits the request for consultation to "qualified" NPPs who are capable of implementing the treatment plan the consultant suggests. Therefore, the most qualified NPPs may be limited to a nurse practitioner, physician assistant, clinical nurse specialist, or certified nurse midwife.

Some of your pulmonologist's consultations will be for patients undergoing surgery, either before or after the procedure. The patient most likely will have a chronic medical condition that may affect or be affected by the perioperative course; and the consult is designed to answer the question: "Can this patient go through with the surgery and survive afterwards?"

See "Know When to Code for Pre-Op Consult" on page 84 for examples of how to answer this question.

The most common pre-op inpatient consult occurs when a patient presents to the ED and the surgeon admits the patient for surgery, but the patient has a comorbid condition that requires surgical clearance or risk assessment (as in the examples on page 84). In these cases, the surgeon requests a consult for the pulmonolo-gist's opinion regarding the patient's stability for surgery.

When your pulmonologist performs this inpatient consultation, report the most appropriate choice from 99251-99255 (Inpatient consultation for a new or established patient ...), depending on the level of service.

Inpatient consultations can be pre- or postoperative, depending on the situation. If a patient's pulmonary disease is exacerbated by the surgery or a new pulmonary problem emerges following surgery, your pulmonologist might be asked to perform a post-op consult.

A pulmonologist who performs a postoperative evaluation of an inpatient at the surgeon's request may bill the appropriate consultation code "when all of the criteria for the use of the consultation codes are met, and that same physician has not already performed a preoperative consultation," according to Chapter 12, Section 30.6.10 of the Medicare Claims Processing Manual.

Watch out for two instances, however, when you should not use a consult code:

1. If the pulmonologist provided and reported an outpatient consultation for perioperative risk assessment for a patient about to undergo surgery and the surgeon requests a preoperative or postoperative inpatient consult for the same patient, you cannot report another consult. Instead, code these services with subsequent hospital care codes (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...).

"There needs to be appropriate documentation to support the use of the [inpatient] consultation codes," Merrill says. "Make sure an opinion or advice on a specific matter is being sought, and the service is not a general routine post-op medical management."

2. In the hospital, the pulmonologist who performs a pre-op consult and assumes responsibility for some or all of the patient's conditions during the post-op period "should use the appropriate subsequent hospital care codes to bill for the concurrent care that is provided," states CMS.

When you submit a consult claim, you should also include documentation that explains the consultation circumstances. Documentation requirements for consults vary by payer, Merrill offers.

But experts say your consult documentation should at least include evidence of:

Note: A separate report sent to the requesting physician is not required when the requesting physician and consultant share a common medical record (which always occurs in the inpatient setting).