Pulmonology Coding Alert

When another practitioner requests your pulmonologist's opinion about a patient's condition, you should report a consult code.
 
Example: A patient with a chronic cough (786.2) and complaining of shortness of breath (786.05) presents to her primary-care physician (PCP).
 
After extensive testing, the PCP cannot establish a diagnosis and asks a pulmonologist to evaluate the patient and give his opinion regarding the patient's condition and possible treatment methods.
 
The pulmonologist examines the patient for and determines the patient may be asthmatic. Therefore,  the pulmonologist decides to perform a baseline spirometry test.
 
The spirometry reveals that the patient has decreased lung function consistent with asthma (493.xx). He administers a bronchodilator to relax the patient's bronchial tubes (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes) and retests the patient's pulmonary function. The pulmonologist sends the PCP a report with his diagnosis and his recommendation for follow-up.
 
Note: If the pulmonologist administers bronchodilator and spirometry on the same day, you should report 94640 and 94010 (Spirometry ...). You should report the second spirometric testing with modifier -76 (Repeat procedure by same physician) appended to the spirometry code   (that is, 94010-76).  

Coding advice: The pulmonologist's service qualifies as an office consultation, and you should report the appropriate code from the 99241-99245 range depending on time spent with the patient, key components, and level of problem severity, in addition to the other procedure codes (94010 and 94640).

Transfers Define Referrals

Without a request, you won't be expected to produce a report. A referral, on the other hand, is the transfer of responsibility for a patient's care from one physician to another, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver.

Example: A 23-year-old woman with a slight fever (780.6) and productive cough (786.2) reports to her internist. The internist orders a chest x-ray, and the radiology report indicates that the patient may have pneumonia.

The internist refers the patient to a pulmonologist for treatment. Because the internist does not ask the pulmonologist to render an opinion on the patient's condition, the pulmonologist should code his service with a new patient office visit code (99201-99205).

"Doctors frequently say to patients things like, 'I'm going to refer you to a specialist to see exactly what your problem is.' But they aren't clear when they say the word 'refer,' and this can spell trouble for coders trying to choose a correct E/M service code," Hammer says.
 
The bottom line: Don't report a consult unless another physician requests it and your pulmonologist sends a report back to him.

Communication Is a Must

Remember: Although Medicare requires you to send a written report back to the requesting physician, CPT isn't as specific. The January 2002 CPT Assistant states, "CPT nomenclature does not specify what form the communication must take.
 
"The consultant may call the requesting physician or other appropriate source on the phone to discuss his or her findings, or he or she may write a report and send it to the requester. If the communication is verbal, the phone call and the discussion during that phone call should be documented by both the physician requesting the opinion and the consultant providing the response."

Tip: If you bill to Medicare and other insurers that  follow Medicare guidelines, you do not have to submit a written report. Since your physician may not confirm the insurance of each of his patients at the time of service, coding experts suggest providing the same standard of care for all patients (e.g., providing written communication). This will minimize billing discrepancies as well as potential liabilities

Red flag: Billing a consultation code when the service doesn't meet the definition of a consult can land a practice in hot water with the Office of Inspector General and with the state attorney general - not to mention invite an audit.

If you report a consult without fulfilling the requirements, you may overbill, coding experts say.

Documentation Is Vital - Be Careful When Using 'Refer'

Pulmonologists must pay particular attention to their documentation - whether they request or deliver a consultation - to provide an accurate record of the patient's treatment.

Always make sure that the pulmonologist documents the request for a consultation in the patient's record, whether the initial request is verbal or written.
 
Carriers require this documentation to consider the consult code valid. Under the best circumstances, you should keep documentation of this request in the patient's charts - both at the requesting physician's office and at your office.

When your pulmonologist reports back to the requesting physician after a consult, you should  avoid the word "refer." Instead of saying, "Thank you for referring John Doe to me ...," the pulmonologist should write, "Thank you for your request to render a consultation ..."

Consult With Treatment? Append -25

Pulmonologists often face denials when they perform a consult and provide treatment on the same day, but you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for these services and fight denials when necessary.
 
Your carrier may deny the consult as bundled with certain procedure codes even when modifier -25 is used, says Sandi Hamrick, CPC, coder at a private practice in Ohio. "It sounds like this particular insurer is not following CPT guidelines, which most certainly allow for a consult and treatment to be billed, but is instead following its own rules."

Solution: The practice should appeal the denial with copies of documentation from CPT, Hamrick says. CPT states that you should separately report any specifically identifiable procedure (identified with a specific CPT code) performed on or subsequent to the date of the initial consultation.

'Request' Rules Differ for Confirmatory Consults

You should report "A 'consultation' initiated by a patient and/or family, and not requested by a physician" using the confirmatory consultation codes (99271-99275, Confirmatory consultation for a new or established patient), according to CPT.
 
And you can code for these consults when an insurer or third party seeks a second or third opinion.
 
CPT says that confirmatory consults are for "rendering an opinion and/or advice only. Any services subsequent to the opinion are coded at the appropriate level of office visit, established patient, or subsequent hospital care."

New/established: You can use 99271-99275 for new or established patients when the patient wants a second opinion and when an insurer requests a specialist's opinion. The pulmonologist can provide confirmatory consults in any setting.

If an insurer requests the consult to determine medical necessity prior to covering a procedure or service, report the appropriate code and append modifier  -32 (Mandated services).