Pulmonology Coding Alert

This lightning round will help you report these often-reported services.

Many pulmonology practices are working to boost income at their offices, and one of the best ways to make that happen is to ensure that you’re reporting your most frequently-billed codes properly. After all, if you are billing a particular code the wrong way, and that code happens to represent 10 percent of your billings, then it’s likely that 10 percent of your income is coming in at the wrong amount.

We’ve compiled a list of the top-five most frequently-billed codes by pulmonology practices, based on data shared with Pulmonology Coding Alert by Frank Cohen, MPA, MBB, of healthcare consulting firm DoctorsManagement. We then put together a lightning round of tips that can help you ensure that you’re reporting each code in the top five properly. Read on to ensure that you can bring more cash into your practice with these coding tips.

#1 Most Frequently Billed Code: 99232

This subsequent hospital care code represents 12.55 percent of pulmonologists’ claims, making it the number one most frequently-reported code in this specialty.

Tip: If you are using history as one of the two elements in your code selection (between history, exam, and medical decision-making), code 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components…) requires an expanded problem-focused interval history. This should include a brief HPI(oneto three elements) and problem pertinent review of systems (ROS) or an inquiry about the system directly related to the problem(s) identified in the HPI.

Example:  “Mr. Smith was admitted yesterday with shortness of breath and lung pain. He has pain on the left side when he breathes deeply (location). His pain has decreased to 2/10 when resting on three liters of oxygen (severity) but is aggravated to 6/10 painwith standing, coughing, or sneezing (context). Mr. Smith denies any dizziness (nervous system).”

Best Practice Guideline: If you use medical decision-making as one of the two components in selecting subsequent services, this will satisfy medical necessity that most payers use as their overarching criterion for E/M service.

#2 Most Frequently Billed Code: 99214

The level-four office visit code comprised 9.48 percent of pulmonologists’ claims last year, showing that the majority of outpatient E/M codes billed in this specialty were 99214s.

Tip: There’s good news about using this code, which is long overdue.

Although you’re required to perform a detailed exam to report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity…) when using the exam as one of the two code selection elements, CMS does not specifically publish, in actual numbers, how many organ systems or body areas the pulmonologist must examine to qualify for a detailed exam. Some payers were advising doctors to report anywhere between two and seven body areas — which was exactly the same as what the expanded problem-focused exam required, creating confusion.

Now hear this: Effective July 1, Part B MAC National Government Services (NGS) announced that it is updating the exam requirements, and now detailed exams will require six to seven body areas or organ systems, whereas expanded problem-focused exams will only require two to five.

“Citing the same scope of examination for both levels has led to frequent provider confusion on documentation requirements and coding selections, as well as a degree of subjectivity in reviewing medical records for these services,” NGS said in its announcement of the update. “This change will eliminate the confusion and bring NGS into alignment with other CMS-sponsored review entities.”

Best Practice Guideline: Check with your payer (if not in a NGS area) to ensure its requirements. Some contractors may have developed rules they will continue to follow (e.g., Novitas Solutions implemented the 4x4 Rule: Four elements in each of four systems equates to a detailed exam).

#3 Most Frequently Billed Code: 99233

This subsequent hospital care code represented 9.09 percent of pulmonologists’ claims in 2016. Because 99233 is the highest level of subsequent hospital care, documentation requires two of these three criteria: a detailed history, detailed exam, and/or high-complexity medical decision-making (MDM).

Tip: You can also report 99233 based on time if you meet the documentation requirements, and CPT^® assigns a 35-minute time threshold to this code. Although many coders think of time-based E/M coding only as an outpatient strategy, it’s perfectly acceptable to use time as your overarching code selection criteria in the inpatient setting, as long as you meet the guidelines.

Ensure that the following three factors are documented in the hospital record if you select 99233 based on time: The total time spent with the patient (which should be at least 35 minutes), the time spent counseling/coordinating care, and a description or summary of the counseling/coordination of care provided.

For instance, “Saw the patient for 35 minutes face-to-face; 20 minutes of that visit was spent counseling the patient and her daughter about her COPD diagnosis, potential treatment options and prognosis; answered multiple questions and provided them with educational information.”

Best Practice Guideline: In order to select time, more than 50 percent of the total visit time must be spent counseling/coordinating care. Otherwise, you must rely on the key components for visit level selection.

#4 Most Frequently Billed Code: 99213

This level-three outpatient E/M visit code comprised 6.15 percent of pulmonologists’ claims last year. This code requires two of the following three criteria: an expanded problem-focused history, an expanded problem-focused exam, and/or medical decision-making of low complexity.

To meet the expanded problem-focused history requirement, you’ll need at least a brief history of present illness (HPI), and one ROS. When documenting a brief HPI, “the medical record should describe one to three elements of the present illness,” Part B MAC CGS Medicare says in its 99213 guidelines.

Those one to three elements can be selected from the following list: Location, severity, context, modifying factors, quality, timing, and associated signs/symptoms, CGS indicates. “You must also document at least one element from the review of systems to obtain an overall result of extended problem-focused history for a level 99213,” adds Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla.

If you don’t have this level of HPI, your history won’t justify reporting 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity…), but all is not lost. Because 99213 only requires you to meet two of the three elements, you can still report the code if your exam is at least expanded problem-focused and your MDM is of at least low complexity.

Best Practice Guideline: As with 99232 (above), if you use medical decision-making as one of the two components in selecting subsequent services, this will satisfy medical necessity that most payers use as their overarching criterion for E/M service.

#5 Most Frequently Billed Code: 99291

Pulmonologists reported the first hour of critical care in 5.30 percent of claims last year. Remember that although this code does include services like pulse oximetry blood gas testing, and ventilator management, there are other services that you can report in addition to 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) when performed.

Services that you should report with 99291, when performed and documented, include intubation (such as 31500, Intubation, endotracheal, emergency procedure), tube thoracostomy (32551, Tube thoracostomy, includes connection to drainage system [e.g., water seal], when performed, open [separate procedure]), CPR (92950), or the insertion of a Swan-Ganz line for monitoring (93503)

Best Practice Guideline: When documenting critical care time, be sure that the note clearly distinguishes this time from the separately billable procedure time.

For more information: Full reports of the most frequently-billed codes by pulmonologists are available at http://shop.doctors-management.com/Procedure-Code-and-Modifier-Utilization-Workbook_p_111.html.