Pulmonology Coding Alert

Answer: If the physician has documented that more than 50 percent of his session with the patient was spent on counseling and coordinating care, report code 99215, which CPT states as an office or other outpatient visit for the evaluation and management of an established patient. Counseling and/or coordination of care with other providers or agencies are provided consistent the nature of the problem(s) and the patients and/or familys needs.

Also, in conjunction with code 99215, report code 99354, which is used to report the first hour of prolonged service on a given date. CPT calls for the use of code 99354 for prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of an acute asthmatic patient an outpatient setting).

Often carriers will not pay for 99354, a headache which doctors may be able to avoid by negotiating with their carriers reimbursement for patient counseling and education services. A negotiation strategy should promote such patient services as disease management designed to save the carrier money by reducing hospitalizations and acute care conditions.

If counseling and education services are provided by a physician assistant and not the physician, the services should be billed as incident towhich means that the physician assistant does not have a separate identification number with commercial payers, and youre billing the service under the doctors name and identification number. Billing under the physicians name has two critical implications:

The physician assistant, also called a physician extender, must be supervised by the physician during the service;
The physician extenders training for this service is within the scope of their state license;

The physicians contract with his carrier must specify that the service, although performed by a physician extender supervised by the doctor, is being billed under the physicians name.

Under Medicare a physician extender, if his training is within the scope of state licenses, can bill the service out as incident to using the doctors Medicare number. But the doctor must be present in the office during the service. If the doctor is not present, the physician assistant must bill out under his own Medicare number and not incident to.

Editors note: Advice for this question was provided by Barbara J. Cobuzzi, CPC, CHBME, president of Cash Flow Solutions Inc., physician reimbursement specialists in Lakewood, N.J.