Pulmonology Coding Alert

Remember Medicare's no-go consult rule first and foremost.

When CMS stopped paying for consults in 2010, some practices eliminated them from the code lineup completely, while others kept using them, but threw the CMS rules out the window. The reality is that you must still know the differences between consults and transfers of care to report these services, because some private payers still reimburse for them.

Read on to learn documentation tips, coverage issues, and payment differences for your consultation and transferred pulmonology cases.

Learn This Ironclad Transfer of Care Rule

Before you approach the consultation codes, you need to know whether a transfer of care occurred, or whether the referring physician wanted your doctor's opinion. Although the difference may seem subtle, this is the most important factor when deciding whether to report a consult.

Key: The American Medical Association's consultation policy (http://www.sccma-mcms.org/portals/19/assets/docs/cpt-consultation-services.pdf) better illustrates these circumstances. "Consultation codes should not be reported by the physician who has agreed to accept transfer of care before an initial evaluation but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial consultation evaluation, regardless of the site of service," the document states. When your pulmonologist accepts the transfer prior to the initial evaluation and treats a patient following such a transfer, it clearly leads you to treating your pulmonologist's E/M service as a transfer, not a consultation.

You should code transfers performed in the office with 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components...) for new patients and 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components ...) for established patients.

Example:  At her annual physical, a 34-year-old patient complains of lung pain upon exercising. Her internist diagnoses the patient with exercise-induced asthma and refers the patient to your practice, where she has not been seen before. Your pulmonologist accepts the transfer, and meets with the patient in the office and performs a level three office visit where they discuss a management plan and potential medications.

Solution: You should code the initial visit with the pulmonologist with 99203 (Office or other outpatient visit for the evaluation and management of a new patient...). This service pays about $110 (2017 Medicare Physician Fee Schedule non-facility rate).

Consideration: If the internist was not able to diagnose the patient and referred the patient for consultation with your pulmonologist, you may have been able to report 99243 (Office consultation for a new or established patient...), which pays $123 (same fee details). If the internist was unable to diagnose the problem, and the role of the pulmonologist was to initiate a diagnostic workup to define the problem, a transfer of care prior to the initial evaluation is unlikely since the pulmonologist may not know if the patient's symptoms are pulmonology-related.

Bottom line: A transfer means that one physician asks another physician to take over the care of the patient for a known condition needing treatment. The patient won't return to the referring provider for additional care for that specific problem.

Finesse Consultation Opportunities

You can see from the prior example that the consultation code pays more than the comparable office E/M code. That actually represents a trend, with consultation codes typically paying more than similar-work office or inpatient E/M codes. That means you can't afford to miss a consultation when circumstances warrant.

"In the simplest of terms, a consultation is a type of service where another physician or nonphysician practitioner requests a doctor's advice, opinion, or recommendations about a patient's problem; that doctor sees the patient, and he provides a written report back to the requesting clinician with his advice, opinion, or recommendations," says Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Fla.

Remember the 3 Rs: To correctly code a consult, the documentation must reflect three criteria - Requested opinion, Rendered service, and Reported results to requesting provider. If those aren't documented, you can't bill a consultation.

Once you've identified that your provider did, in fact, perform a consultation, you need to choose the right code to report. Consultations are categorized into two types, as follows:

• Office/other outpatient consultations (99241-99245, Office consultation for a new or established patient, which requires these 3 key components ...).
• Inpatient consultations (99251-99255, Inpatient consultation for a new or established patient, which requires these 3 key components...)

Coding Tip: Never use the term "referring physician" when dealing with a consultation, but choose a term such as "requesting physician" instead. This will avoid confusion for both billers and auditors.

Alert: Medicare and some other payers don't recognize the consultation codes 99241-99245 and 99251- 99255. For those payers, you'll need to bill an inpatient or outpatient E/M code just like you would for "regular" E/M services (or for referrals, which use the same codes). Be sure that those that do recognize consults use the AMA guidelines as their standard.