Pulmonology Coding Alert

Here's a claim example that should help ease your prolonged service cases Just because your pulmonologist interacts with a patient for different periods of time throughout a day of service doesn't automatically disqualify you from charging for prolonged services. 

The prolonged service codes do require "face-to-face" patient care, meaning that the pulmonologist must have personally interacted with the patient/patient's parents exclusively during the prolonged service time. But that doesn't mean the time must be continuous.

You can still report prolonged services if the pulmonologist provides prolonged service during different time segments throughout the course of a day, coding experts say.

Example: A pulmonologist provides a nebulizer treatment to an asthmatic patient. He spends 50 minutes evaluating the patient initially and provides a
comprehensive history, comprehensive exam, and MDM of high complexity. He then has the patient stay for observation while he tends to other matters.

An hour later, the pulmonologist returns to the patient and spends another 40 minutes explaining the results to the patient and discussing treatment options with the parents.

The claim for this example should read:

 99215 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history, a comprehensive examination, medical decision-making of high complexity

 +99354 - Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (list separately in addition to code for office or other outpatient evaluation and management service).  Explanation: The pulmonologist spent a total of 90 minutes on the E/M service, far beyond the 40 required to report 99215. Appending 99354 helps your office recoup money for the extra time the pulmonologist had to dedicate to performing the service. As long as you have the proper documentation of the time the pulmonologist spent with the patient, the prolonged service code is admissible.

If the pulmonologists does not spend more than 50 percent of the base E/M time counseling and/or coordinating care, you should not select the base E/M level based on time. Instead, you should select your base E/M level based on the sum of the key components (history, exam, medical decision-making). 

Then, subtract the visit time associated with that level from the total visit time and report this with prolonged care codes.

Remember: When reporting prolonged service codes and procedure codes on the same claim, make sure you are coding the total E/M time, not the total time of the visit. Deduct the time spent on the procedure from the prolonged service time, or your office could be in trouble for double-billing.

Also, do not add in [...]