Pulmonology Coding Alert

You've been on the fence for tow years now on consultation coding for a specific problem, and CPT 2008 didn't answer any of your questions. But you can confidently code a consult despite the "transfer of care" language if the encounter passes this litmus test.

In 2006, CMS redefined a transfer of care as one that occurs "when a physician or qualified NPP [nonphysician practitioner] requests that another physician or qualified NPP take over the responsibility for managing the patient's complete care for the condition and does not expect to continue treating or caring for the patient for that condition." The revision caused confusion over whether cases in which a pulmonologist sees a patient at the request of a physician for care of a specific condition could qualify as a consult.

"The answer is yes and no," according to Patrice Morin-Spatz, coding expert with MedBooks in Richardson, Texas.

Solution: ''It's yes if the scenario can pass this two-prong test," says Morin-Spatz, past-editor of the AMA's CPT book. When considering a consultation code, ask

1. When is the diagnosis reached?

2. When did treatment begin?

Key: You may consider the visit a consultation when the diagnosis or the treatment is not known prior to the service, if the requesting physician words the request for opinion appropriately. Recommended documentation indicates a request for opinion or advice regarding a specifically stated problem or symptom (such as shortness of breath).

Apply the above two questions to this scenario: A primary-care physician (PCP) sends a patient to the pulmonologist for an evaluation. Does the initial visit's request qualify as a consult? It depends on what the PCP is asking for in his request to the pulmonologist.

The visit can qualify as a consultation if the PCP knows the condition and is asking for the pulmonologist's opinion relative to an appropriate treatment plan, Morin-Spatz says.

Example 1: The PCP's request states, "Patient wheezing indicates that he may suffer from asthma. Please provide further workup, as well as your opinion on possible treatment options."

In this case, the patient's reatment hasn't been confirmed as the appropriate plan of care. Therefore, the pulmonologist is truly rendering an opinion. If the initial pulmonologist encounter meets the other consultation criteria including a report back to the PCP, you may code the visit with 99241-99245 (Office consultation for a new or established patient ...).

Best practice: The physician can further stress that he rendered an opinion by using "requesting" terminology in his report, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. A good "requesting" statement would be, "Thank you for requesting my opinion on treating Patient X's persistent cough."

Requests specifying the treatment may fall short of a consultation.

Example 2: The PCP's request indicates, "I am sending to you an emphysema patient who needs further testing and treatment for the condition." The request doesn't meet a consultation's intent for opinion, Morin-Spatz says. Instead, the report is a transfer of care for a specific condition.

So you would code an office visit (99201-99215, Office or other outpatient visit ..., depending on whether the patient was new or established).

Remember that CMS has stricter consultation guidelines than CPT. You don't have to apply CMS rules across the board. "When dealing with [non-Medicare] payers, I tend to use the CPT definition," says Donelle Holle, RN, professional fee services manager for the University of Michigan Health Systems.

Using dual consultation coding guidelines means keeping track of which rules to follow with which patients. "When treating the patient, the doctor should not have to worry about what insurance a patient has," Cobuzzi says.

To keep both consult coding policies straight, consider three tactics:

A. Safe way: Implement one standard for everyone. This implies that you follow Medicare guidelines for all and ensures you cover all bases when billing any insurer. This method offers the least risk for the least effort from the practice staff.

B. Color route: Paper offices can put a bright-colored sticker on Medicare charts so that the doctor can be aware of Medicare patients, Cobuzzi says. For nondesignated -- private-payer -- charts, the physician could code the encounter using CPT guidelines. This method requires increased practice effort to update the chart "colors" as often as they update the patient's insurance information, and it doesn't account for secondary payers that may follow Medicare policy.

C. Policy path: "Research what the individual carrier has adopted as a guideline for consultations, and have the guideline in your office on file," writes Teresa Thompson, CPC, CMSCS, CCC, TM Consulting president, in "Understanding Consults" offered by the American Academy of Allergy, Asthma & Immunology.

(Need a tool to strengthen your consult coding documentation? Check out the next article, "Navigate Transfer-of-Care Waters With This Guide.")