Pulmonology Coding Alert

You aren't responsible for the requesting physician's files, CMS says

CMS lets pulmonologists off the verification paper-trail hook, drops one critical care bundle and creates numerous moderate sedation bundles. Here's what you need to know to seamlessly implement these changes.

Change 1: No Need to Confirm 1 Consultation 'R'

Recent Medicare rules have had pulmonologists worried that they'd be responsible for other physicians' consult request documentation. CMS now says that this isn't the case, but it hasn't offered new guidance on how it will handle "incomplete" consult requests.

New rule: "On April 18, 2006, the PRIT (Physician Regulatory Issues Team) released a statement stating that they do not expect the consulting physician to verify that the ordering physician has documented the consultation request in the patient's chart," writes Diane Daigle, president of Maine Medical Group Management Association.

In other words: When a primary-care physician requests a consult from a pulmonologist, the specialist isn't responsible to make sure the PCP's files include that request in writing.

But CMS officials still insist that the requesting physician has to document the request for a consult, as CMS stated in last December's Transmittal 788. The only change is that the consultant doesn't have to verify that the initiating doctor has done so.

So, what will happen if the carrier audits the consultant and doesn't find any request documented in the PCP's files? Will the specialist still get paid? At this point, CMS hasn't been able to answer that question.

"It is a real paper chase for the consultant to have to look at the referring physician's notes to see if they are in compliance," says Roberta Buell, vice president of provider services and reimbursement with P4 in Sausalito, Calif. CMS should delete the requirement for the requesting physician to document the request for a consult altogether, she adds.

The issue isn't resolved: CMS officials say they're not planning to clarify the consult issue any further--unless providers or carriers indicate that they're still having problems. CMS doesn't even plan to put out a transmittal or manual update spelling out this latest clarification partly letting consulting physicians off the hook.
 
Best advice: As always, you should let documentation guide your coding. Now more than ever before, the consultant must have a reason and request for a consult documented in the patient's medical record, along with an opinion rendered by the consulting physician, with a written report sent to the requesting physician.

Experts also recommend adding the "fourth R" of returning (or discharging) the patient back to the requesting physician when the episode of care is complete. Remember: The "return" does not always occur at the end of the consultative service. The consultant is permitted to initiate treatment, when appropriate, and still report a consultation. When the consultant completes the course of treatment, eventually discharging the patient from his care, a notation in the medical record helps to distinguish between ongoing care and future consultation requests.

The four R's of a consultation for 2006 are (* indicates new this year):

• reason/request: medically necessary--both the requesting and consulting physician must document the reason and request for the consultation. But the consultant doesn't have to verify that the requesting physician did so*.

• render: the pulmonologist may initiate diagnostic and/or therapeutic services.

• report: issue a written report back to the requesting source.

• return (recommended): send the patient back to the referring physician*.

Change 2: Separately Code Critical Care, Discharge

In the most recent National Correct Coding Initiative edits, version 12.2 (effective July 1, 2006), CMS deleted an edit that made critical care codes 99291-99292 components of hospital discharge day management code 99239 (Hospital discharge day management; more than 30 minutes). Now that CMS has deleted this edit, if your pulmonologist provides 30 minutes or more of critical care to a patient and then provides an additional 30 minutes of discharge services for the patient, you can bill for both services.

Prior to July 1, CMS considered 99291-99292 (Critical care, evaluation and management of the critically ill or critically injured patient ...) and 99239 to be mutually exclusive services. Mutually exclusive edits pair procedures or services that the physician would not reasonably perform on the same date, during the same session, or on the same anatomic location for the same beneficiary, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Previously, if you were to report these two mutually exclusive codes for the same patient on the same date, insurers would generally pay for the comprehensive procedure (in this case the discharge 99239) and deny the payment for the component service (the critical care 99291 and 99292). Due to these problematic edits, payerswould reimburse the less expensive service because they include all E/M services provided on the day of discharge in the discharge day management codes.

Warning: If reporting these two services for the same patient on the same date, be sure that the service and the documentation reflect two services, occurring during two separate time intervals. You cannot report two services for the same 30-minute interval. Despite the removal of the NCCI bundle, standard critical care rules apply. Per CPT and CMS, "time spent performing separately reportable procedures or services should not be included in the time reported as critical care time."

Change 3: Use 59 When 2 Rxs for Draw, Hydration

A few short months ago, NCCI version 12.1, which took effect April 1, classified 107 codes as components of moderate sedation (99143-99150).

Translation: You should be appending an appropriate modifier (such as modifier 59, Distinct procedural service) to bill for moderate sedation used with intracatheter introduction (36000), venipuncture (36400-36410, 36420-36425), hydration (90760) and many injection procedures. This change is Medicare's way of saying that it won't pay separately for any of these procedures in addition to moderate sedation.

Exception: If the procedures meet the criteria for modifier 59, you can report them together, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. In addition, NCCI 12.1 made numerous procedures components of 90760, she says.

For instance, you shouldn't typically report venipuncture requiring a physician's skill in addition to hydration, according to NCCI 12.1, Pohlig says. But if the blood draw is for a different reason than hydration assessment (such as a CBC to detect infection) and occurs at a separate site from the hydration insertion, you can code both.

In this case, you should report the venipuncture and the hydration (90760, Intravenous infusion, hydration; initial, up to 1 hour), Pohlig says. You would append modifier 59 to the component code: 36410 (Venipuncture, age 3 years or older, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes [not to be used for routine venipuncture]).

Good news: The bundles might not affect your reimbursement for non-Medicare payers. Non-Medicare payers may indeed pay for 99143-99150, and you can always specify reimbursement for moderate sedation during your contract negotiations. So don't assume private payers won't reimburse you just because Medicare won't.