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Pulmonology Coding Alert

Established Patient Visits:

Dont Miss Out on Money

Published on Mon Oct 01, 2001

Similar to coding for new patient visits (see September 2001 Pulmonology Coding Alert), coding for established patients can be challenging. While 99211-99215 outline the requirements for these office and outpatient visits, ensuring that a pulmonology practice realizes fair and accurate reimbursement can be more involved than is apparent.
 
As with new patient codes, each established patient code specifies an amount of time spent with a patient and/or family. However, as Walter ODonohue, MD, FCCP, FACP, chairman of the CPT committee of the American College of Chest Physicians (ACCP) and a representative to the AMA CPT advisory committee for ACCP, explains, The history, examination and level of decision-making are the key components in determining the level of the code used. Time becomes the primary factor only if counseling or coordination of care with other professionals is involved. 
 
Carol Pohlig, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania, explains the difficulty in coding these established patient visits. Practices tend to undercode these visits because the health problems and medical history are familiar, she says. Thus, even though the amount of work and the level of decision-making are actually quite complex, the physician may inadvertently code at a level lower than warranted because the medical decision occurs in a quicker manner.
 
She adds that Physicians do not realize they are not audited based on the time it took to make a medical decision. They are audited based on their thought processes and how well they document how they arrived at a medical decision. Documentation is the most important factor. Physicians need to be careful to include all of the systems reviewed and all the procedures performed for complete reimbursement.

The First Level
 
 
The simplest visit is coded 99211 (office or other outpatient visit), for the E/M of an established patient, which may or may not require the presence of a physician. Usually the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.
 
This code encompasses a visit for a limited problem that may not need the services of a physician. For example, a 63-year-old patient with chronic obstructive pulmonary disease (COPD) who takes various medicines and uses several treatments becomes confused about the amount and frequency of each. 
 
Needing guidance in comprehending and adhering to his regime, he presents at the pulmonologists office and is educated by the nurse in the proper way to take the medicine. In this example, the level of care suggested by this code is minimal, both in the time spent with the patient and the complexity of the service performed.
 
The Second Level
 
The next level of care is covered by 99212 (office or other outpatient visit), for the E/M of an established patient, which requires at least two of these three key components:  
 
a problem-focused history
 
a problem-focused examination
 
straightforward medical decision-making.
 
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs.
  
Usually, the presenting problem(s) are self-limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.
 
A typical example of a visit covered by this code is a three-month routine visit by a COPD patient who is stable. The pulmonologist listens to the lungs but, because the patient is doing well, has no signs of exacerbation and needs no adjustments to the medicine, the examination and history are limited and focused, falling under the guidelines for this code.

The Third Level
 
The third level is covered by 99213 (office or other outpatient visit), for the E/M of a new patient, which requires at least two of these three key components:
 
an expanded problem-focused history
 
an expanded problem-focused examination
 
medical decision-making of low complexity.
 
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs.
  
Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.
 
For example, a 53-year-old woman with COPD presents at the pulmonologists, complaining of orthopnea, 786.02. After examining her, the physician recommends that she sleep with her head raised, either by using more pillows or elevating the head of her bed. According to Pohlig, this visit is billed on this level because the history and exam are more involved and the medical recommendation more complex than for the preceding codes.

The Fourth Level
 
The fourth level is 99214 (office or other outpatient visit), for the E/M of an established patient, which requires at least two of these three key components: 
 
a detailed history
 
a detailed examination
 
medical decision-making of moderate complexity.
 
 
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs.
 
Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.
 
This code is for a medical problem that is more complex and serious, for example, a COPD patient with a mild exacerbation who presents at the pulmonologists office complaining of mild dyspnea, 786.00. After an examination, the physician adjusts her bronchodilator, prescribing an increase in the aminophylline. In this instance, the examination and history are detailed and the medical decision-making is moderately complex as indicated by the nature of the patients problem.

The Fifth Level
 
The most complex code is 99215 (office or other outpatient visit), for the E/M of an established new patient, which requires at least two of these three key components:
 
a comprehensive history
 
a comprehensive examination
 
medical decision-making of high complexity.
 
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs.
  
Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.
 
For example, a 60-year-old COPD patient presents at the pulmonologists office, complaining of severe shortness of breath, 786.05. During the examination an x-ray is taken, revealing a shadow in the lungs. The physician schedules a bronchoscopy to evaluate the abnormality suggested in the x-ray. This visit fulfills the requirements for a level-five established patient visit because of the severity of the problem and the complexity of the services performed.

Report All Services and Procedures
 
 
Because detailed documentation is so important when billing established patient visits, pulmonologists must write down all services and procedures performed to eliminate any inadvertent omissions. If the documentation is complete, a practice can pass a review of any materials requested.

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