Pulmonology Coding Alert

Pulmonologists are often called to the ED to evaluate patients. The provision of these services presents significant coding questions, according to Karen Bloxham, RN, BSN, specialty case manager, whose Milwaukee-based-company provides specialty insurance to businesses, associations, financial service organizations and individuals.

There are several ways to code that relate to this situation, and it can be confusing if you just look at the CPT manual, she says. A common problem is distinguishing between ED (99281-99285), critical care (99291-99292) and consultation codes (99241-99275.) Sometimes, it comes down to the language the physician used in the patient record, says Bloxham. He or she might have written, for example, Consulted with Dr. A re: patient in ED. The generality of this leads to confusion. The coder focuses on the word consulted and chooses one of the consultation codes rather than a more appropriate ED or critical care (CC) code.

When To Use ED Codes

These codes are used strictly to report E/M services delivered to a registered patient within the ED only, says Bloxham. CPT 2001 defines ED as an organized hospital-based facility for the provision of unscheduled episode services to patients who present for immediate medical attention. The facility must be available 24 hours a day. However, Section 15507c in the Medicare Carriers Manual (MCM) notes that the services provided in the ED do not have to constitute an emergency; it simply is a physician service for an unanticipated visit by the patient who is registered. More important, a non-ED physician can report an emergency code.

As an example, Bloxham describes a pulmonologist called to the ED regarding a 40-year-old male who has not seen the doctor in more than a year. The patient is having trouble breathing but is maintaining oxygen saturation rates. The physician examines him, decides on a course of treatment, prescribes the appropriate medications and instructs him to make an appointment to be seen in the office the following day. The likely code choices in this situation would be 99281-99285, the level depending on the three key components of history, examination and degree of medical decision-making.

When To Use Consultation Codes

Codes 99241-99275 are used if the physician is asked by the ED doctor to see a patient with pulmonary complications and the requirements of a consult are fulfilled:

The ED physicians request must be in writing and documented in the medical record;

The pulmonologist sees the patient; and

A written report detailing the treatment prescribed must be provided to the ED physician.

A typical situation might involve a young child. Since an ED physician may not be familiar with pediatric doses and treatments for juvenile asthma, for example, a pulmonologist may be called on for an opinion. The pulmonologist is not responsible for the childs ongoing care and, therefore, should use a consultation rather than an ED code.

When To Use a Critical Care Code

Codes 99291-99292 are used in the ED if the requirements for CC are met:

The patient is critically ill or injured, although not necessarily unstable;

The patient requires constant attention by a physician; and

At least 30 minutes of care are given.

These codes reflect the time when the physician is engaged in work that is directly related to the patients care. This includes:

Time spent reviewing tests results;
Discussing treatment with other medical staff; and
Documenting services, and speaking with family members if those discussions have a direct bearing on the care, but do not include time spent giving simple updates or providing emotional support.

According to CPT 2001, the first 30 to 74 minutes of critical care, even if they are not continuous, are billed using 99291. It can be used only once on a given date. Code 99292 can be reported as many times as needed and is used for each additional 30 minutes. For example, 60 minutes of CC in the ED for an emphysema patient would be billed using 99291 x 1, while 160 minutes of such care would be billed as 99291 x 1 and 99292 x 3. Although called critical care, these services can be provided in units other than the CCU or ICU.

Coding for Patients Seen in Office Earlier in Day

Occasions may arise when a patient seen in the office during the day is examined later in the ED. If two separate medical problems are involved (two diagnosis codes are used), both the office and ED visits are billed, with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code. For example, if a pulmonologist treats a 60-year-old male for chronic obstructive pulmonary disease (COPD) in the office, this would be coded as an established patient visit (99211-99215) whether for flare-up of the disease or simply for a routine, scheduled checkup. If, later that day, the pulmonologist sees the same man in the ED for acute chest pain, this is billed separately, and as a result, modifier -25 would be added to the E/M code with supporting documentation.

However, according to Jan Johnson, executive vice president of The Profile Group, a reimbursement and compliance advisory firm in St. Paul, Minn., a payment problem arises if the two visits to one physician on the same day deal with the same medical problem. Some carriers will deny one of them because there are two codes being billed for the same thing, Johnson says.

If the pulmonary physician sees a patient in the ED and later that day admits him or her to the hospital, Johnson advises that the doctor bundle the time spent in the ED with that spent in the office and bill a higher-level under the admissions code (99221-99223). If, however, the patient is not admitted to the hospital, both visits cannot be billed because they involve the same diagnosis code. Either the E/M or the ED code is assigned with the work from both visits factored in.