Pulmonology Coding Alert

Check out the top five CPT^® codes reported by pulmonologists, based on CMS data.

1. 99214

Pulmonologists reported 99214 (Office or other outpatient visit for the evaluation and management of an established patient …) on 11.37 percent of claims last year, according to CMS data.

When considering 99214, make sure your physicians understand that medical necessity should be driving the code choice. Automated systems set up to document every possible piece of history and examination for every patient will certainly attract the attention of auditors if they lead you to check off more history and exam elements than necessary, prompting you to report a higher-level code.

2. 99232

Reported on 11.29 percent of all pulmonologists’ claims last year, 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient …) came in second on the list.

This subsequent hospital care code is on the Targeted Probe and Educate (TPE) active review lists for some of the Medicare Administrative Contractors (MACs), so you should be aware of the documentation requirements before reporting it.

3. 99233

Pulmonologists billed 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …) on 9.36 percent of all claims in 2019, according to CMS data.

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).

Of the three E/M components — history, exam, and MDM — you must fully document two components meeting the level of the E/M code selected to justify use of each subsequent care code. If there is little or no documentation, then you need to change the code.

4. 99213

Coming in fourth on the list was 99213 (Office or other outpatient visit for the evaluation and management of an established patient …), which was reported on 5.98 percent of all pulmonology claims.

When choosing between 99213 and 99214, pay attention to the differences in the descriptors, which we’ve bolded:

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, medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient›s and/ or family›s needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.)

99214 (… a detailed history, a detailed examination, medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.)

Remember that you need two out of three elements to report the service, unless you’re billing based on time. So, if your documentation reflects a detailed history, an expanded problem-focused examination, and low-complexity MDM, the right code is 99213 and not 99214, despite the detailed history.

5. 99291

Rounding out the top five, 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) appeared on 5.83 percent of Medicare claims for pulmonologists. The critical care code can be reported when a physician or other qualified healthcare professional directly provides medical services for a critically ill or critically injured patient, no matter where the encounter takes place. As always, the documentation must support the necessity of the critical care service, and time spent must be thoroughly documented since these codes are time-based.