Pulmonology Coding Alert

With thorough documentation and careful language when you code consultations, you can ensure a stress-free claim process void of any fights with insurers over denials. Follow these strategies coding experts have offered for optimal reimbursement.

When you are deciding whether to bill for a consultation (99241-99245) as opposed to an office visit (99201-99205, 99211-99215), remember the three R's of consults: request, review and report, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm in Lansdale, Pa.

Refer to the following examples the next time you report a consult:

Request: The primary-care physician (PCP) or another physician, such as an internist, must formally request a consultation from your pulmonologist. Your physician must document the need for a consultation in the patient's medical record. For example, a patient presents to his or her PCP and complains of a cough (786.2) and chest pains (786.5x) that have lasted more than a month. In a letter, the PCP explains the situation and requests that the pulmonologist examine the patient and provide a diagnosis, Falbo says. Your pulmonologist can document the request in his own note. In the inpatient setting, the requesting physician must have a documented written request in the medical record. Because the chart is shared, the consultant may not document the request. The PCP should document the inpatient request in his progress note or as a separate order.

Review: A consultation review always involves a suspected problem and an unknown course of treatment. Your pulmonologist reviews the requesting physician's comments (if available) regarding the patient's cough and chest pains. After your physician examines the patient, he diagnoses the problem as chronic bronchitis (491.x) and advises the requesting physician on a course of action, Falbo says.

Report: Now your physician writes a report of his findings (bronchitis) and includes the suggested treatment plan to the requesting physician in the last paragraph, Falbo adds.
 
The report provides an opportunity for your pulmonologist to document the requesting physician's request, says Lois Geist, MD, a pulmonologist with the University of Iowa Healthcare's department of internal medicine in Iowa City. For example, "Thank you for requesting this consultation" or "I saw your patient in consultation today." Make sure your physician always uses "request" instead of "refer." An auditor may misinterpret "refer" as a transfer of care, she says
 
Include Essential Documentation

 When you report a consult, you must supply specific documentation of all three components: history, exam and medical decision-making, Falbo says.

Use the following clinical examples as a guide for what documentation carriers require for each level of care.

99241 Your pulmonologist evaluates a patient with a cough. Your physician listens to the patient's lungs, diagnoses the problem as a cold, but doesn't prescribe medicine, which represents low-level, straightforward decision-making. PCPs seldom request that a pulmonologist treat patients at this level.

99242 A patient presents with cold symptoms but also has a history of allergies. Your pulmonologist listens to the lungs and examines the ears, nose, mouth and throat to determine whether the patient has a cold or allergies. Your physician prescribes rest, which he documents.

99243 Your pulmonologist evaluates a patient for suspected bronchitis. Your physician reviews previous medical records, exams the lungs, ears, nose, and throat in detail, and identifies the past family history of pulmonary disease. Your pulmonologist determines that the patient has the flu and prescribes over-the-counter meds, which he or she documents in the report.  

99244 A problem at this level requires a moderate level of risk to the patient's health. For instance, a PCP requests that your pulmonologist evaluate a patient with shortness of breath (786.05). Your physician diagnoses the problem as intrinsic asthma (493.10 without mention of status asthmaticus or acute exacerbation or unspecified). Then your pulmonologist develops a treatment plan that includes initiating bronchodilator therapy 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]).

99245 Your pulmonologist diagnoses a patient as asthmatic with an acute exacerbation (493.92). Your physician recommends inhalation therapy for acute airway obstruction and prescribes steroids. However, the patient has a history of diabetes (250.0x without mention of complication), and your pulmonologist recommends that the patient perform frequent finger sticks to monitor how the steroids influence his blood sugar. Because the patient has a chronic illness with acute exacerbation, and the drug therapy requires monitoring for toxicity, you can report 99245 for high-complexity decision-making.

Transfers vs. Consultations Know the Difference

Make sure you know the difference between a transfer of care and a consult when you bill for evaluation mixing up the two could raise red flags to auditors.

The Medicare Carriers Manual (MCM) states that a transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of the referral, and the receiving physician documents approval of care in advance, Falbo says.

For instance, your pulmonologist diagnoses a patient with viral pneumonia (480.x) during a consultation. After the patient's PCP carefully reviews your physician's report and records, he decides that your pulmonologist's care would better serve the patient. The PCP decides to transfer care. You bill the original encounter as a consult, and report any subsequent care your pulmonologist provides as an established visit (99211-99215).

Also, many patients refer themselves to a particular pulmonologist, Geist says. Consider a patient whose PCP treats him for allergies but performs no tests. After the patient is unable to achieve the results that he expects, he decides to visit your pulmonologist for allergy testing and a different plan of care that might be more beneficial.

You should check your insurer's local medical review policy (LMRP) for specific guidelines on transfer of care, Falbo says. According to some LMRPs, transfers do not necessarily mean that the receiving pulmonologist will manage all the patient's conditions. For example, Blue Cross Blue Shield of South Carolina states that you cannot bill for an initial consultation if, subsequent to completion of the consultation, the physician assumes responsibility for managing even a portion of the patient's care.