Pulmonology Coding Alert

With thorough documentation and careful language when you code consultations, you can ensure a stress-free claim process void of any fights with insurers over denials. Follow these strategies coding experts have offered for optimal reimbursement.

When you are deciding whether to bill for a consultation (99241-99245) as opposed to an office visit (99201-99205, 99211-99215), remember the three R's of consults: request, review and report, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm in Lansdale, Pa.

Refer to the following examples the next time you report a consult:

Request: The primary-care physician (PCP) or another physician, such as an internist, must formally request a consultation from your pulmonologist. Your physician must document the need for a consultation in the patient's medical record. For example, a patient presents to his or her PCP and complains of a cough (786.2) and chest pains (786.5x) that have lasted more than a month. In a letter, the PCP explains the situation and requests that the pulmonologist examine the patient and provide a diagnosis, Falbo says. Your pulmonologist can document the request in his own note. In the inpatient setting, the requesting physician must have a documented written request in the medical record. Because the chart is shared, the consultant may not document the request. The PCP should document the inpatient request in his progress note or as a separate order.

Review: A consultation review always involves a suspected problem and an unknown course of treatment. Your pulmonologist reviews the requesting physician's comments (if available) regarding the patient's cough and chest pains. After your physician examines the patient, he diagnoses the problem as chronic bronchitis (491.x) and advises the requesting physician on a course of action, Falbo says.

Report: Now your physician writes a report of his findings (bronchitis) and includes the suggested treatment plan to the requesting physician in the last paragraph, Falbo adds.
 
The report provides an opportunity for your pulmonologist to document the requesting physician's request, says Lois Geist, MD, a pulmonologist with the University of Iowa Healthcare's department of internal medicine in Iowa City. For example, "Thank you for requesting this consultation" or "I saw your patient in consultation today." Make sure your physician always uses "request" instead of "refer." An auditor may misinterpret "refer" as a transfer of care, she says
 
Include Essential Documentation  When you report a consult, you must supply specific documentation of all three components: history, exam and medical decision-making, Falbo says.

Use the following clinical examples as a guide for what documentation carriers require for each level of care.

99241 Your pulmonologist evaluates a patient with a cough. Your physician listens to the patient's lungs, diagnoses the problem as a cold, but doesn't prescribe medicine, [...]