Pulmonology Coding Alert

Consultant codes are initiated when one physician requests an opinion or advice from another physician, says Jan Johnson, executive vice president of The Profile Group in St. Paul, Minn., which advises hospitals and physicians on reimbursement and compliance issues. In determining whether a patient visit is a consult (99241-99245, office or other outpatient consultation), she says to look for these three elements to be present:

1. The patient has to have been sent by another
physician asking for the specialists opinion;

2. The receiving physician must examine the patient
and document in writing what was done; and

3. The pulmonologist must then send recommend
dations back to the physician who sent the patient.

Consider a case where a primary care physician (PCP) has a patient complaining of a cough that has lasted more than a month. The PCP sends the patient to a pulmonary specialist, asking in a letter for a diagnosis. The pulmonologist examines the patient, diagnoses the problem and sends the PCP a suggested treatment plan to carry out. Consult or referral? Most would say this is a clear-cut example of a consult.

What if the PCP asks a pulmonologist to evaluate and treat the patient for the cough? Is that a consult or referral? Most say thats a referral because the PCP is transferring care of the patient for that problem to the specialist.

The first thing the carriers look for is the name of the physician who is sending the patient, says Carole Fatato, division coordinator at Cooper Hospital Pulmonary and Critical Care in Camden, N.J. She has had claims based on consultant codes denied when the name of the sending physician was inadvertently left off the claim. If they dont have a referring physician, theyll [carriers] automatically deny it, she warns.

Some experts contend that the regulations say a transfer of care occurs only if a physician transfers total care for the patient to the specialist. Ray Painter, MD, of Physician Reimbursement System in Denver, says that unless the specialist is asked to take over total care for the patient, then a consultation applies. If that referring physician is going to see that patient again, then the transfer of the total care of the patient probably didnt occur, Painter says.

For example, if a patient has a chronic pulmonary disease and the PCP wants to hand all of that patients care over to a pulmonary specialist and doesnt want to see the patient again, that would be a transfer of care. But if this is an acute problem the patient is having, and he will go back to see the primary care physician after that problem is corrected, then that would not be a transfer of care, he says.

Determining When Its a Transfer

Sometimes, however, the intentions of the sending physician are not clear. Even a written request can be confusing in its wording. When a physician writes the request for a consult, what he or she needs to do is say, I want your opinion, and thats all, says Pat Booth, RN, director of government relations for the National Association of Medical Direction of Respiratory Control. If the physician writes that he or she wants the pulmonologist to evaluate and follow this patient, its not going to be a consult because a transfer of care has already occurred. Similarly, pulmonologists who are billing for a consult should not write back to the sending physician saying, Thank you for referring this patient to me. Booth says, That sounds like a transfer of care to the carrier.

Nancy DeMarco Lamare, CPC, a coding specialist in Monmouth, Maine, agrees that physicians written communications can be problematic. Weve told the doctors that with the written reports, dont say thanks for the referral. That can hurt you when the insurance carriers want to see your notes.

A transfer of care is considered to have taken place if the pulmonologist winds up treating the patient. But even if a transfer takes place, sometimes a consult can still be claimed during the process. When the transfer occurred thats really the hinge of it, Booth says. If the sending physician asks the pulmonologist in the requesting letter to evaluate and treat the patient, thats considered a transfer of care and should be billed with the office/outpatient evaluation and management (E/M) codes (99201-205, new patient; 99211-99215, established patient), Booth explains.

If the sending physician asks for an opinion and after receiving it decides the pulmonologist should treat the patient, that would be a transfer of care, but the original encounter (between the patient and the pulmonologist) is a consult. You can bill only once for a consult, then when you saw the patient again you would bill whatever was the appropriate E/M code, Booth says. As part of the consultation, the pulmonary specialist can order diagnostic tests as well as therapeutic measures, as long as the physician who sent the patient agrees, she adds.

Consults In the Hospital Setting The rules for consultations are sometimes different when the patient is seen in an emergency room and/or admitted to a hospital. Of concern to pulmonologists is what codes they should bill so that they are paid for their time spent with a patient. Sometimes a pulmonologist may see a patient in the office for one problem, such as shortness of breath, and later that same day the patient presents in an emergency room with a related problem, such as a mild heart attack. Some experts say the pulmonologist cant bill for two E/M services in one day and the doctor should bill just for the ED visit, 99281-285. You cant charge a 99213 in the morning for shortness of breath and later in the day charge a 99214 in the ED, explains Nancy DeMarco Lamare, CPC, a coding specialist in Monmouth, Maine. Others say that the physician can bundle the time spent in the office and in the ED into one code. Still others tell us the pulmonologist can bill for both an office visit and then bill an ED visit the same day. The place of service is different and usually the diagnosis would be different, Cesario says. Jan Johnson, executive vice president of The Profile Group in St. Paul, Minn., agrees. Those are two distinct services, and the pulmonologist could bill an office visit and could bill in one of two ways: They can use the ED codes or they could use another office visit code at whatever level of service was rendered, she says. The ED service codes are appropriate and reasonable if providing emergency service. The only question would be if some payer wouldnt pay for two visits to the same physician on the same day. But some payers will see the emergency doctor billing an ED code and then the pulmonologist billing an ED code, and deny one of them because there are two codes being billed for the same thing, Johnson says. If the pulmonary physician sees a patient in the ED and later in the same day admits the patient to the hospital, Johnson advises that the physician bundle the time spent in the ED and bill a higher level under the admissions code. CPT instructs offices to code several visits for the same day for the same problem to the most comprehensive visit for the day (for example: an office visit early in the day and an admission later in the day for the same problem would be coded as an admission), while visits for two different problems should be coded separately, using the -25 on one of the E/M codes. Check with your individual carriers to determine whether they recognize two ED codes by different physicians on the same day, or whether they prefer the ED visit to be coded by the ED physician, with the other physician coding either an outpatient services code (99201-99215) or outpatient consultation code (99241-99245) depending on the service rendered. There are also situations that you can well imagine where you see the patient in the ED and then up on the floor and their status is changing, and youre really having to re-examine them and youre really doing a lot of work on that admission and youre already on level 3, Johnson said. Then what you do is use prolonged service codes (99354-99357) that are added to and billed along with an admission code that provide some additional time spent with the patient.