Pulmonology Coding Alert

Question: A new patient visited our office with breathing problems. The physician took a comprehensive history and conducted a thorough examination. After diagnosing asthma, the physician used the session for asthma education wherein she spent two hours supplying education and materials for the patient. How should we code this visit?

Washington Subscriber

Answer: If the physician has documented that she spent more than 50 percent of the total face-to-face time with the patient on counseling and coordinating care, this is an eligible case to bill based on time. Since the single encounter is being billed on counseling time, CMS requires “in those evaluation and management services in which the code level is selected based on time, prolonged services may only be reported with the highest code level in that family of codes as the companion code.” In the scenario above, you can report E/M code 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity…) to account for the first 60 minutes of then encounter. Also, in conjunction with code 99205, report prolonged services code 99354 (Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]) to account for the remaining 60 minutes of the encounter. CPT^® calls for the use of code 99354 for prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of an acute asthmatic patient an outpatient setting). Appropriate codes should be selected for supplies provided or procedures performed in the care of the patient during this period.

Support the E/M visit with diagnostic codes 493.10 (Intrinsic asthma, unspecified) and 786.05 (Shortness of breath). After the ICD-10 changes take place from Oct. 1, you will have to report asthma from the code family J45.-- (Asthma) and 786.05 will convert to R06.02 (Shortness of breath).

Sometimes carriers may ask for detailed notes for justifying 99354, or outright deny the claims. You can appeal with the payer by providing a copy of the progress note, which should supply the details of the counseling, as well as a copy of any patient materials reviewed and provided to the patient. Check your local payer policies thoroughly before billing such cases.

If counseling and education services are provided by a physician assistant and not the physician to a non-Medicare patient, it means that the physician assistant may not have a separate identification number with commercial payers, and you’re billing the service under the physician’s name and identification number. Billing under the physicians name has two critical implications:

The physician assistant (PA-C) must practice under the general supervision of a physician; (You should note, however, that supervision for PA-Cs is not a billing requirement; it is a licensure requirement, which does not mean the same thing for billing purposes. Licensure mandates general supervision.

The physician assistant’s training for this service is within the scope of their state license;

The physician’s contract with his carrier must specify that the service, although performed by a physician extender supervised by the doctor, is being billed under the physicians name because there is no other mechanism to bill for the service in the NPP name.

Under Medicare a physician extender, if his training is within the scope of state licenses, can bill the service out ONLY under the physician extender’s Medicare number. Counseling time is not permitted as an “incident-to” service. Face-to-face time refers to the time with the billing provider only. Per CMS Manual, “Counseling by other staff is not considered to be part of the face-to-face physician [or NPP] -patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service.”