Pulmonology Coding Alert

Warning:  CMS won't allow you to report a consultation code for shared or split visits

Reporting your pulmonologist's consultations won't be so daunting anymore thanks to a new CMS transmittal. If you can show differences in expertise, you can now officially report and expect reimbursement for consultations between physicians in your practice.

The Physician's Area of Expertise Makes a Difference

The most significant clarification in CMS Transmittal 788 is that if your pulmonologist works in a group practice, you can still report and be compensated for consultations that he provides for other physicians in the group. But to ensure reimbursement, the consultant must have knowledge and expertise that go above and beyond that of the requesting physician's.

This requirement will apply to pulmonology groups in which the physicians have pulmonary subspecialties, as well as to more diversified practices that might include physicians in other specialties such as thoracic surgery or general medicine. While it's been pretty clear that you could report consultations within a group between physicians with separate specialties, same specialty consultations within the same group were not clearly allowable, says Deborah J. Grider, CPC, CPC-H, CPC-P, CCS-P, EMS, president of Medical Professionals Inc. in Indianapolis.

Tip: This guideline also clarified that physicians should not routinely request a consultation from another member of their group, Grider says. Your protocol cannot be that if a patient comes in to see Dr. A, he then automatically sends the patient to Dr. B after he finishes his examination. Make sure your office can prove that the pulmonologists have separate sub-specialties and that there is a medical necessity for the second physician to see the patient in consultation.

Transfer of Care Eliminates Consultation Code Options

Make sure you don't report a consultation if there is a transfer of care between physicians in the same group, says Nancy Reading, RN, BS, CEO of Cedar Edge Medical Coding and Reimbursement in Centerfield, Utah. If the second physician assumes care of the patient, a consultation code is appropriate, as the following examples demonstrate.

Example 1: In a group of pulmonologists, one provider is a general pulmonologist and another specializes in interventional pulmonology. The general pulmonologist sees a new patient who presents with an unspecified lung mass. A computed tomography scan reveals a possible tumor.

The general pulmonologist asks the interventional pulmonologist to take over the care of the patient since it will require diagnostic interventions. Because the first pulmonologist sent the patient to the other physician to care for this new problem, the visit is probably a transfer of care and not a consult, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. In this example, the interventional pulmonologist should report the appropriate established patient office visit code for the encounter since a physician in the group previously saw the patient.

Example 2: A general pulmonologist has been following a patient with chronic obstructive pulmonary disease (COPD) for many years. The patient develops breathing problems during sleep. The pulmonologist performs a sleep study during which the patient demonstrates moderate to severe sleep apnea.

The physician refers the patient to a pulmonary colleague who specializes in sleep medicine for consultation with evaluation and treatment of the sleep disorder. The general pulmonologist continues to follow the patient for his COPD. Since this would stand up as a request for an opinion, you can report a consultation code for the patient's visit with the sleep specialist, Plummer says.

Forego Split Visits for Consultations

Good news: Your nonphysician practitioners (NPP) are still able to report and request consultations, according to CMS' transmittal.

Bad news: The agency also clarified that you cannot report a consultation that involves a shared or split visit between the pulmonologist and the NPP. Some practices may have been previously advised by their carriers not to use shared visits for consultations, but this may be a significant change for some physicians.

"I think the rule that excludes split visits for consults will be a problem for most practices using NPPs," Plummer says. "Not allowing this will definitely limit the role of the NPP in the practice."

Often in pulmonology practices, a nurse practitioner performs the patient workup. The pulmonologist then provides a key portion of the service "face-to-face" and bills for the whole visit. Shared visits such as this are not permissible with consultations. Therefore, when your pulmonologist is performing a consultation, your office's nurse practitioner or physician assistant can only contribute the review of systems or past medical, family and social history toward the documentation and visit level that the physician provides and selects.