Pulmonology Coding Alert

You can bill initial visits again on re-admission of a discharged patient.

When your pulmonologist provides a consultation in a hospital setting, including emergency situations or has a role in admitting a patient for hospital treatment, you could be forfeiting pay for those services if you’re unaware of the following coding advice.

1. Site of Service Decides Patient Status

Make sure the patient your pulmonologist attends has been admitted as an inpatient. “This is because all patient stays do not necessarily qualify for ‘inpatient’ status. Even if the doctor saw the patient in the hospital setting, the patient’s condition may only require admission to observation,” cautions Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.   

Inpatients include patients admitted to hospitals, partial hospital settings or nursing homes. For inpatient services by your physician in a hospital, you can report from the code range 99221-99239 (Hospital Inpatient Services) or 99251-99255. For nursing home settings, you should choose from the code range 99304-99318 (Nursing Facility Services).

Caution: Consultations within the ED or for patients admitted to observation status, as well as for residents of domiciliary, rest (boarding) homes, custodial care or other -non-skilled- facilities are not inpatient services.

Therefore, reporting codes from 99217-99226 (Hospital Observation Services), 99281-99288 (Emergency Department Services), or 99324-99340 (Domiciliary, Rest Home [e.g., Boarding Home]…) in the inpatient setting should get your alarm bells ringing.

2. Distinguish Between “Admission” and “Consult”

Many coders think they can bill for an initial inpatient visit just because the doctor performed a history and physical exam in the office before admission. Because he dictated the history and physical for the patient without a face-to-face visit in the hospital, the doctor may think the practice can bill an initial inpatient visit, but this is wrong. 

For example: A 65-year-old patient presents to the out-patient office location with chest pain, severe breathing difficulties, and blood tinged sputum that started a few days before the visit. The pulmonologist decides after performing a comprehensive history and physical examination that the patient needs to be admitted as she has severe lung infection.

He advises admission to the hospital for respiratory support, antibiotic fluids and further testing, and sees the patient in the hospital to complete the admission process. In this scenario, you should report the admission and not the office visit beforehand. You will report the admission with initial hospital care codes (99221-99223). The admitting physician (pulmonologist or another physician) is considered the “the attending physician of record” and has to use the initial services code with modifier AI (Physician of record). “When a ‘consultant’ performs an initial visit on a Medicare patient in the hospital, you should also use an initial hospital code from 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:…), 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:…), or 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:…), according to Medicare’s consultation guidelines. Absence of the AI modifier alerts the payer to the consultative nature of the service,” adds Pohlig.

For instance, if the pulmonologist performs a comprehensive history, comprehensive exam, and moderate complexity medical decision-making on a Medicare inpatient, you’ll choose 99222 instead of reporting an inpatient consult code (99251-99255) for this patient. The inpatient consultation codes are no longer accepted by Medicare, but can be used for non-Medicare patients.

3. Report Initial Pulmonology Consult Only Once Per Patient 

If you are sure that the patient is a registered inpatient, you should choose an appropriate-level initial inpatient consultation code from 99251-99255 (Initial Inpatient Consultation Services) for the pulmonologist’s first encounter with the patient when your services are requested. Don’t forget to check for the relevant documentation needed to support and qualify a consultation.

Caution: You can report 99251-99255 only once per patient per hospital stay.

For example, the attending physician requests your pulmonologist to provide a consultation for a hospital inpatient recovering from surgery and complaining of breathing difficulties. The pulmonologist conducts a full history and examination, prepares a report of his findings, and shares them with the managing (requesting) physician via the hospital chart.

In this case, you may report an initial inpatient consult code (such as 99254, Inpatient consultation for a new or established patient…), as well as any diagnostic tests the pulmonologist provides (for example, 31622, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]).

Watch out: Don’t forget to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) to the consult code if the pulmonologist provides a same-day procedure (such as the bronchoscopy).

4. Keep Your Cool for Re-Admissions and Follow-Ups

You are in safe territory if the patient is discharged and re-admitted later that same year because you can confidently report another inpatient consult if the condition of the patient is significantly different and medical necessity requires a full re-evaluation of the patient. Assuming all components of an inpatient consult are documented, then you may again report 99251-99255 for non-Medicare patients or 99221-99223 for Medicare patients. “If the pulmonologist’s documentation fails to meet the minimum requirements for the initial hospital care codes (99221: detailed history and exam; low complexity decision making), then you must choose from the follow-up hospital visit codes 99231-99233,” informs Pohlig.

Example: The patient in the above-given example leaves the hospital only to be re-admitted 10 days later. The managing physician finds that the patient’s previous condition has worsened and once again requests a consult from your pulmonologist. You may again report 99251-99255, as appropriate.

5. Pick the Correct Coding Level

Just like the office setting, all notes must contain the information to substantiate the level of charges being submitted for the services rendered. Unlike new office patient codes (99201-99205) and established office patient codes (99211-99215) where there are five coding levels, there are only three coding levels for initial hospital care codes (99221-99223) and the subsequent hospital care codes (99231-99233). The confusion is increased because the documentation and complexity of a ‘level 1 Initial Hospital Care code’ corresponds closely with a ‘level 3 New Patient Code.’ Only the most complicated hospital visits will necessitate a level 3 code (99223 or 99233), as these correspond to level 5 outpatient services. Hospital-visit coding and documentation has been a frequent target of Medicare audits and remains an area of risk for physicians who don’t follow the documentation guidelines for these services.