Pulmonology Coding Alert

Consultations and referrals continue to confuse many pulmonology coders. But by understanding the key elements that make up these services, coders can better distinguish them and code accordingly.

In general, a referral means a request for, or the ordering of, a designated health service (DHS) by a physician. A referral also includes a request for a consultation with another physician and any test or procedure ordered by the physician-consultant.

Consultation Becomes a Referral

Pulmonary physicians often are asked to perform a consult (99251-99255) during which the patients condition deteriorates and he or she must be admitted to the intensive care unit (ICU) where care is transferred to the pulmonologist. At what point does the consult become a referral?

The difference actually lies in the intent. If Dr. A wants Dr. B to take over the care of the patient for a particular problem, then its a referral. If he just wants an opinion and then, based on that opinion, decides to transfer care, the initial visit for Dr. B is a consult. I approach it from this angle because it is Dr. A that makes it a consult or a referral, points out Mary Lou Laughner, CCS-P, CPC, senior coding consultant at Health Systems Management Network, a healthcare consulting firm with a national practice in Chatham, N.Y.

So how do you code if the patient is moved from a consultation visit to an ICU and under the pulmonologists care for observation? How should the documentation reflect that the consulting physician did not expect to assume care at the time of consultation?

Carol Pohlig, CPC, RN, a reimbursement analyst for the office of clinical documentation, Department of Medicine at the University of Pennsylvania in Philadelphia, asks, Were there two visits or one? If the consultant performs the consultation service prior to the patient being transferred to the ICU, for example, a consultation service was performed and should be billed. There is no requirement to document that care was not assumed at the time. The consultant was not aware that the transfer was going to occur before the service was initiated. Consultants are allowed to initiate diagnostic and/or therapeutic interventions at the time of consultation.

Consultation Followed by Procedure

A pulmonologist is asked to perform a consultation on a patient who has a lung mass (786.6). After the consultation exam, the pulmonologist performs a bronchoscopy. The physician attempts a transbronchial biopsy, but the patient doesnt tolerate intubation and starts to gag and cough. The sedation is reversed, and the patient moves to the operating room, where the patient experiences blood clot formations, making biopsy specimens difficult to acquire. The total time for the procedure extended to five hours.

Code 31628 (bronchoscopy [rigid or flexible]; with transbronchial lung biopsy, with or without fluoroscopic guidance ) with modifier -22 (unusual procedural services) would be appropriate for this example. The -22 modifier identifies a service greater than usually required for the listed procedure. Basically, the modifier represents an increment of work rarely encountered for the particular procedure and also not identified by another specific CPT code.

Pulmonologists also should remember to charge more. If the procedure took five hours, include the costs in your claim. Not all insurers automatically increase the reimbursement, so submit a copy of the operative report or the patient chart notes and a written statement by the physician in simple and specific terms (Five extra hours because of gagging reflex, blood clot development and relocation to operating room).

Walter J. ODonohue Jr., MD, chairperson of the CPT committee of the American College of Chest Physicians (ACCP) and a representative to the AMA CPT advisory committee for ACCP, suggests a second approach to the scenario. Quite often, the -22 modifier proves difficult for carriers to approve, so another approach would be to treat these as two separate procedures. You could report 31622 (bronchoscopy [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]) with modifier -53 (discontinued procedure). Bill the operating room activity as 31628 with modifiers -22 and -76 (repeat procedure by same physician) appended.