Pulmonology Coding Alert

Question: Our pulmonologist was consulted to see a hospital patient who had Medicare. I billed 99213. Was it correct? She spent approximately 20 min. with the established patient and also visited the patient the next day for 25 min. Provider also saw another Medicare outpatient observation patient for two days (about 30 min.). What E/M would I use for the visits? 

Alabama Subscriber

Answer: No. Code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:…) is not correct. If your physician visited a hospital inpatient, you would select an E/M code from initial hospital care series of codes (99221-99223) for the initial service. The code selection is not based on time unless >50 percent of the service focused on counseling/coordinating care. Otherwise, the visit code selection is based on the extent of documentation for history, exam, and MDM. For the next day’s visit, you may report from subsequent care E/M codes. Here, 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:…) may be more appropriate. 

Place of service is crucial. If the patient is in “outpatient observation status” in the hospital and has Medicare and your physician is the consultant (i.e., not the observation attending of record), then you should use the appropriate outpatient code based on whether the patient is new or established to your practice.  If the patient has been seen by someone in your group of the same specialty, then you can report the appropriate established patient code (99212-99215) for each day, provided you fulfill the key components. If the patient is new to your group, then report the appropriate new patient visit (99201-99205) for the initial encounter and an established patient visit for the subsequent encounter.