Pulmonology Coding Alert

A pulmonologist who bills inpatient hospital visits as concurrent care should emphasize the condition he or she is treating, which may not be the same reason the patient was admitted to the hospital.

Concurrent care occurs when two or more physicians treat the same patient on the same day. The patient's condition must warrant the services of more than one physician on an attending basis, which means the patient will probably have different diagnoses that require treatment by physicians of different specialties.

For example, a pulmonary physician admits a diabetic patient to the hospital for pneumonia (486). The patient's diabetes (250.0x) has been exacerbated by the pneumonia. The pulmonologist treats the patient's pneumonia, while an internist or endocrinologist treats the diabetes. Because the pulmonologist admitted the patient to the hospital, he or she would report one of the initial hospital care codes (99221-99223). Both physicians would be able to bill subsequent hospital care codes (99231-99233) to cover the continuing evaluation and management of the patient. Neither doctor would need to append a modifier (e.g., -25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the hospital care codes to report the concurrent care visits unless the physicians are part of the same group billing under the same tax identification number.

The key to being consistently reimbursed for concurrent care is to stress the different conditions (diagnoses) being treated. Pulmonologists should link their services to the condition they are personally treating. In the example above where the pulmonologist and the internist are providing concurrent care, the pulmonary physician should list pneumonia (486) as the primary diagnosis code, says Teresa Thompson, CPC, a pulmonology coding and reimbursement specialist in Sequim, Wash. "Even though the diabetes is considered in the pulmonologist's medical decision-making, he or she should not list the code."

Meanwhile, the internist should list diabetes as the primary diagnosis on his or her claim. "This will support the medical necessity of both physicians attending the patient on the same day," Thompson says.

Toni Revel, CPC, a coding expert and nurse practitioner based in Warrington, Pa., agrees: "Both physicians reporting the same diagnosis, even as a secondary diagnosis, can lead to a claim rejection, especially in this case when they are similar specialties, i.e., both branches of internal medicine."

Pulmonologists must also be able to document that their services were medically necessary. Stopping by the patient's room to see how he or she is doing or for a social visit does not constitute concurrent care. The same components of all E/M visits history, examination and medical decision-making or counseling/coordination of care time must be part of the concurrent care visit.

In addition, the patient's medical record should detail the specific services provided by the pulmonologist. It should reflect the physician's active involvement with the patient, and there should be sufficient documentation to determine the role each physician played.

When two physicians see a patient in the intensive care unit (ICU), some coders may question whether concurrent care services can be reported, believing that if a patient is in the ICU, he or she must be receiving critical care. And only one physician at a specific time can bill critical care, Thompson notes.

Although Medicare allows only one physician to report for a given hour of critical care, a second physician can report a subsequent hospital care code if he or she also provides care to a critically ill or injured patient. More than one physician can provide critical care services to a patient on the same day if the physicians meet the requirement for critical care services. They just cannot provide critical care during the same one hour.

"This is where it is important for the doctors to document the time of the visits because only one physician can provide critical care at a time," Revel says. If the physician seems to be performing a regular hospital visit while another is providing critical care because the documentation lacks time notations, insurance carriers will likely see the care as redundant and refuse to pay, she adds.

Remember that being in the ICU does not necessarily mean the patient is receiving critical care. If the patient is not undergoing critical care, there are no restrictions on reporting concurrent care in the ICU and regular subsequent hospital care codes (99231-99233) should be used, Thompson says.

You should also distinguish between concurrent care and a consultation because inpatient consultations (99251-99255) have higher relative values than the corresponding subsequent hospital care codes. Medicare and CPT have the same three basic criteria for a consultation:

1. A request for a consultation from the patient's physician must be recorded in the patient's medical record
2. The consultant must review the patient's condition
3. The consulting physician must provide a written report of his or her findings to the requesting physician, which can be satisfied with the progress note written in the inpatient chart because this chart is a shared medical record among all the physician specialists involved in the patient's care.

A consulting physician may initiate diagnostic and/or therapeutic services at the time of the evaluation or during a subsequent visit, and the service will be considered a consultation because no transfer of care occurs at the time of the request for an evaluation.

For example, an internist in the hospital requests a pulmonologist's opinion regarding a kidney transplant patient who has developed pneumonia. The pulmonary physician reviews the patient's condition and issues a report to the internist detailing diagnosis and treatment options. He or she also starts the patient on a course of antibiotics. After reviewing the pulmonologist's report, the internist asks the pulmonary physician to manage the patient's pneumonia.

To report the pulmonologist's services, you would bill an initial inpatient consultation (e.g., 99255, Initial inpatient consultation for a new or established patient ) linked to the pneumonia diagnosis (486). Any subsequent E/M services the pulmonologist provides in treating the patient's pneumonia should be reported with subsequent hospital care codes (99231-99233).

Pulmonology coders may get confused about whether a transfer of care has occurred because pulmonary physicians are often asked to manage a portion of the patient's care after the consultation. The pulmonologist should ask what the intent is in seeing the patient. If the physician requesting the consultation only wants to hear an opinion from the pulmonologist, then it's a consultation.