Pulmonology Coding Alert

Question: Our pulmonologist was called in to the hospital by the admitting doctor as a specialist to evaluate a patient in observation. We billed subsequent observation code 99226 for our doctor’s services, but Humana denied the claim, stating that the service we reported “exceeds the maximum number allowed per day” because another subsequent observation service was billed on the same date of service by a different provider (the admitting physician) for the same patient.

Is there a different code we should for a subsequent observation specialist visit if another physician already billed code 99226?

Washington Subscriber

Answer: The reason for your claim denial is two-fold: Subsequent observation care codes (CPT^® codes 99224-99226) can only be billed by the admitting doctor and can only be reported once a day.

Other providers, such as your pulmonologist, who also evaluate the patient should bill a consultation code or an outpatient visit code, as appropriate. Since your physician was called by the admitting doctor to evaluate the patient in observation, you would report the appropriate code from the outpatient consultation code range (99241-99245), depending on the services provided, severity of the complaint, and the time spent with patient/in the unit. If the payer does not accept consultation codes, then you must report an outpatient visit code from the 99201-99215 range for your pulmonogist’s services.

Here’s an example: A 78-year-old male Medicare patient with a medical history of COPD, atrial fibrillation, and aortic insufficiency presents to the ED with chest tightness, dyspnea, and a cough. The patient is admitted to observation to rule out congestive heart failure. His pulmonologist is consulted to rule out COPD exacerbation; the patient is known to the pulmonology practice for his routine care.   Since Medicare does not accept consultation codes, and the patient receives ongoing care from the pulmonologist, the pulmonologist must report an established patient visit, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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. Typically, 25 minutes are spent face-to-face with the patient and/or family) based on the level of service provided.

Caveat: When your physician is the admitting physician in future subsequent observation care situation, and you do report 99226 (Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient’s hospital floor or unit), be sure you can support all the code’s requirements as indicated in the complex description.