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Q&A: How to code for an initial consult; coding for pulmonary function tests; reimbursement when you aren't in patient's plan


Understand the ins and outs of billing new patients, coding for supplies and handling patients who have other managed care plans not covered by your office.

A: You may bill a new-patient level of service if you or one of the same-specialty associates within your group has not seen the patient within the past three years - same specialty meaning the same taxonomy code (specialty/subspecialty) as defined by CMS. Cardiology has no subspecialty taxonomy codes because cardiology is a subspecialty of internal medicine.

If someone within your same tax ID group has seen the patient within the past three years, then the visit must be coded as an established-patient visit (99211–99215). If prolonged services are rendered to the patient in an office setting, then it may be appropriate to charge a 99354–99355 service in addition to the correct evaluation/management service. Codes 99356–99357 are for prolonged services in an inpatient setting but do not represent a covered service for Medicare and most insurers.


Q: I provide pulmonary function tests. I use a filter, updraft, and oxygen tubing in addition to medications. Can I bill for the supplies as well as 94060?

A: You did not indicate which place of service you were providing bronchodilator responsiveness, spirometry, and pre- and post-bronchodilator administration. Typically, code 94060 includes all supplies associated with the provision of the test, with the exception of the medications used prior to repeating the test. Those meds should be reported using the proper "J" code or carrier-assigned code.

Insurers vary in their coverage. Depending on the place of service, tubing, filters, etc., may be covered, but typically they are covered as a facility expense, not a professional expense. Check with the insurer.


Q: If I do not participate in a managed care plan and a patient covered by that plan elects to see me anyway, what reimbursement expectations should I have? If the insurer says the patient has 80 percent coverage, is that 80 percent of my charge or 80 percent of the insurer-allowed amount? Can I bill the patient for the balance?

A: Most managed care plans will allow patients to see providers who are not in their network, but they charge patients to do so by making them pay a higher percentage of the cost. For instance, the patient may have to pay a 20 percent copay amount for in-network providers and the charge for the service. For out-of-network providers, the benefit might be only 80 percent of what the plan would allow for in-network providers. The patient is responsible for both the copay and the penalty for seeing an out-of-network provider.

You may bill or collect from the patient at the time of service. Many times, out-of-network payments are sent to the patient, so you have to collect the entire amount from the patient. If you accept assignment on a particular service, then you may be agreeing to a reduced amount; in essence, the provider, not the patient, may be penalized for the out-of-plan choice.

Medical Economics Consultant Virginia Martin, CPC, CHBC, is president of Healthcare Consulting Associates of NW Ohio Inc. She has more than 30 years of experience as a practice management consultant and also is a certified coding specialist, certified compliance officer, and certified medical assistant. Have a coding or managed care question for our experts? Send it

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