Pulmonology Coding Alert

Details on diagnosis, treatment light the way to consult or referral You've been on the fence for tow years now on consultation coding for a specific problem, and CPT 2008 didn't answer any of your questions. But you can confidently code a consult despite the "transfer of care" language if the encounter passes this litmus test. In 2006, CMS redefined a transfer of care as one that occurs "when a physician or qualified NPP [nonphysician practitioner] requests that another physician or qualified NPP take over the responsibility for managing the patient's complete care for the condition and does not expect to continue treating or caring for the patient for that condition." The revision caused confusion over whether cases in which a pulmonologist sees a patient at the request of a physician for care of a specific condition could qualify as a consult. "The answer is yes and no," according to Patrice Morin-Spatz, coding expert with MedBooks in Richardson, Texas. Solution: ''It's yes if the scenario can pass this two-prong test," says Morin-Spatz, past-editor of the AMA's CPT book. When considering a consultation code, ask 1. When is the diagnosis reached? 2. When did treatment begin? Key: You may consider the visit a consultation when the diagnosis or the treatment is not known prior to the service, if the requesting physician words the request for opinion appropriately. Recommended documentation indicates a request for opinion or advice regarding a specifically stated problem or symptom (such as shortness of breath). Focus on Request Specifics Apply the above two questions to this scenario: A primary-care physician (PCP) sends a patient to the pulmonologist for an evaluation. Does the initial visit's request qualify as a consult? It depends on what the PCP is asking for in his request to the pulmonologist. Look for Opinion on Possible Treatment The visit can qualify as a consultation if the PCP knows the condition and is asking for the pulmonologist's opinion relative to an appropriate treatment plan, Morin-Spatz says. Example 1: The PCP's request states, "Patient wheezing indicates that he may suffer from asthma. Please provide further workup, as well as your opinion on possible treatment options." In this case, the patient's reatment hasn't been confirmed as the appropriate plan of care. Therefore, the pulmonologist is truly rendering an opinion. If the initial pulmonologist encounter meets the other consultation criteria including a report back to the PCP, you may code the visit with 99241-99245 (Office consultation for a new or established patient ...). Best practice: The physician can further stress that he rendered an opinion by using "requesting" terminology in his report, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding [...]