Pulmonology Coding Alert

During the remainder of this year, the Health Care Financing Administration (HCFA) will be scrutinizing two evaluation and management (E/M) codes office or outpatient visit of an established patient (99214) and subsequent hospital care (99233) because a recent audit found these codes to be a common problem area.

In a letter to physicians last month, HCFA Administrator Nancy Ann Min-DeParle congratulated the medical community for its help in reducing the percentage of payment errors from 14 percent to 8 percent over the past four years. The letter, dated June 1, 2000, goes on to describe the results of a more careful look at HCFAs most recent audit of payment accuracy. In one area, HCFA found a number of common errors. We will ask Medicare claims-processing contractors, states DeParles letter, to focus educational and claims-review resources on these areas, and we urge you to take steps internally to prevent them. The full text of the letter is accessible via the Internet at http://www.hcfa.gov/medicare/mip/physltr.htm.

Regarding the codes themselves, the letter issues the following guidance: For physicians, we will be focusing this year on two CPT codes used to report E/M services 99214 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components [detailed history and examination/moderate complexity decision making]) and 99233 (subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components [detailed history and examination/high-complexity decision making]). These codes accounted for a significant portion of the coding errors in the last two audits. In fact, documentation for many of these services was found to be sufficient to support services that more appropriately are described by CPT codes 99212 (office or other outpatient visit...[focused history and examination/straightforward decision making]) and 99231 (subsequent hospital care...[problem focused history and examination/straightforward or low complexity decision making]).

The CPT code descriptors mention specific amounts of time typically required to perform the appropriate level of counseling and coordination of care activities. Time is one of the few guidelines established to help the physician determine which level of E/M to bill. For example, code 99233, the amount of time that a physician typically spends with a patient has been determined to be roughly 35 minutes at the bedside and on the patients hospital floor or unit (in comparison to 99231, which lists 15 minutes as typical). To use code 99233 appropriately, the documentation accompanying the claim must demonstrate that a comprehensive (general multi-system examination or a complete examination of a single organ system) took place. Code 99214 lists 25 minutes as typical (as compared to 10 minutes for 99212).

Extended Care Facilities

On occasion, particularly if a patients needs are primarily pulmonary in nature, a pulmonologist will be responsible for patients residing in extended-care facilities. As the countrys population ages, these facilities will continue to grow, as will the types of facilities.

There are a number of codes pertaining to admission to and treatment within extended-care facilities. But the definition of the term extended-care facility differs depending on the context. Now, on a national level, there is coding for two basic types of extended-care facilities.

According to Cynthia Thompson, CPC, senior consultant at Gates, Moore & Co., a physician practice management consulting firm in Atlanta, if you are admitting a patient to a skilled nursing facility, intermediate care facility or a long-term care facility, the appropriate admission code is 99303 (evaluation and management of a new or established patient involving a nursing facility assessment at the time of initial admission or readmission to the facility, which require these three key components ...) if all the criteria are met, including the creation of a medical plan of care and required assessments.

Occasionally, the code has been confused with initial inpatient consultation codes (99251-99255). Using 99303 is more accurate because consultation codes require opinion or advice requested by another physician or other appropriate source.

One physician may use one code one time (99303), regardless of whether the services related to the admission were performed in the hospital and/or in the extended care facility. Some confusion may exist regarding the medical plan of care if you are using 99303, 99301 (evaluation and management of a new or established patient involving an annual nursing facility assessment ...) or 99302 (evaluation and management of a new or established patient involving a nursing facility assessment ...), says Thompson. The medical plan of care is vital to the use of these codes, and the documentation must at least mention it.

Because 99301 specifies that it is the annual nursing-facility assessment, the care plan must be addressed either by being reviewed and/or affirmed. Codes 99302 and 99303 require the creation of a medical care plan and suggest that roughly 40 and 50 minutes (respectively) of availability at bedside or within the facility unit are needed to accomplish this.

On the other hand, if the patient is transferred to a place that does not include a medical component (determined by the existence or absence of medical personnel within the facility), the more appropriate codes would be 99331-99333 (domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components...). Now there are no typical times established for these codes.

Keep in mind that the pulmonologist can bill these codes only if he or she is the attending physician of record who certifies the plan of care, which sometimes occurs if the patients primary condition is chronically pulmonary in nature. If another doctor is the attending physician of record, however, and he or she asks the pulmonologist to come to a nursing facility and see the patient, the pulmonologist should bill an initial inpatient consultation (99251-99255). Consultations provided in a domiciliary or rest home are billed with codes 99241 through 99245, determined by the place of service. Some states make further distinctions between, for example, nursing facility, skilled nursing facility, adult living center or hospice care. Sometimes, different floors of larger facilities will be licensed differently, so the pulmonologist should determine in which type of facility he or she is working before submitting documentation for reimbursement.

As with admission services, treatment services are divided between those performed at a nursing facility (99311-99313) and those performed at a domiciliary or rest home (99331-99333). Given the nature of domiciliary or rest homes, the most extensive evaluation that can take place there is detailed. In other words, there is no code for a comprehensive examination that takes place in a rest home. More than likely, patients requiring that level of evaluation are transferred to a hospital or skilled nursing facility before the examination takes place.

In general, the type of facility determines the code. However, if a physician assumes that, because the patient is a full-time permanent resident of an extended care facility, he or she can bill for a home visit, most likely reimbursement will be denied.