Pulmonology Coding Alert

Question: A patient was referred to a pulmonologist from their primary care physician (PCP) following an exacerbation of their chronic obstructive pulmonary disease (COPD). The pulmonologist performed a physical evaluation, reviewed and ordered tests, counseled the patient on medication compliance and administration timing, then adjusted the patient’s current medication and ordered an additional prescription. In the end, the encounter lasted for 33 minutes due to the medication discussion.

I can’t verify which tests reviewed were external and which tests the pulmonologist ordered, and this is confusing me when assigning the E/M code.

Can you point me in the right direction?

Michigan Subscriber

Answer: Everything you’ve mentioned points to using 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.) for the evaluation and management (E/M) visit. While the Elements of Medical Decision Making (MDM) table in the E/M services guidelines of the CPT^® code set is very helpful when determining the level of MDM, it’s very easy to overthink the data column.

The table features three columns that factor into your level of MDM determination:

• Number and Complexity of Problems Addressed at the Encounter
• Amount and/or Complexity of Data to be Reviewed and Analyzed
• Risk of Complications and/or Morbidity or Mortality of Patient Management

You need to fulfill at least two of the three columns at a certain level to assign an E/M code based on that level of MDM. In the encounter you’ve presented, the pulmonologist reviewed and ordered tests. As your documentation does not specify what they are, you probably cannot count them as a part of the data element of MDM. However, as you know the patient presented with an acute exacerbation of their COPD (chronic illness with exacerbation) and the pulmonologist adjusted the patient’s medication regimen (prescription drug management), you can use these elements of the encounter to fulfill two of the three elements for a moderate level of MDM.

Also, the patient was referred to the pulmonologist, which indicates the patient is a new patient for the provider. This information leads you to assign 99204 for the encounter.