How clinic payment works — no DRG, sometimes two claims

The ICU page's facility DRG does not exist in clinic — there is no Part A inpatient bundle. Outpatient is paid on the Physician Fee Schedule (PFS). The twist in an academic center: if your clinic is a hospital provider-based department, a second claim is generated — a hospital outpatient facility fee under OPPS.

Your professional dollars come from CPT / E&M codes (work + practice expense + malpractice RVUs × the conversion factor, adjusted by local GPCI). The same code pays a different amount depending on place of service: in a freestanding office you bill the higher non-facility rate (your practice expense is baked in); in a provider-based clinic you bill the lower facility rate because the hospital separately collects the facility fee. That single fact drives most of the academic-clinic billing nuances below.

How tags are used here: Pulmonary-fit especially relevant to subspecialty pulmonary Academic teaching-setting nuance $ lever changes what's paid

Common questions

Office vs provider-based clinic — the academic fork

Most teaching pulmonary clinics are provider-based departments of the hospital, not freestanding offices. That single classification changes the place-of-service code, your professional payment rate, whether a facility fee is generated, and — critically — whether incident-to billing is even available.

Know which one your clinic is before you reason about incident-to (APPs) or expected payment. When in doubt, ask your billing office for the clinic's POS and whether it is registered as provider-based.

Office / outpatient E/M — 99202–99215

Since 2021, outpatient office E/M is leveled by medical decision making (MDM) or total time on the date of the encounter — whichever is more favorable. History and exam are performed as clinically appropriate but no longer drive the level. Pick the path that fits the visit; for a long counseling or care-coordination visit, time usually wins; for a quick but cognitively complex decision, MDM wins.

New patient (99202–99205) & established (99211–99215)

Work RVUs are national CY2026 values; dollars are approximate national non-facility (total RVU × $33.40, rounded). In a provider-based clinic the physician line is paid at the lower facility rate. Local GPCI varies.

What counts toward total time

Total time = all the physician/QHP's time on the date of the encounter, face-to-face and not: reviewing the chart and outside records before the visit, the exam, counseling, ordering tests/meds, documenting in the EHR, and care coordination performed that day. It does not include time on a different calendar day, staff time, or time spent on a separately reported service (e.g., a PFT interpretation or an injection).

MDM, with pulmonary examples (meet 2 of 3 columns)

Two pulmonary MDM levers worth knowing cold: (1) Prescription drug management — adjusting inhalers, starting prednisone, managing a biologic — is moderate risk on its own, supporting 99214. (2) Drug therapy requiring intensive monitoring for toxicity (e.g., immunosuppressants for ILD, theophylline levels) is high risk, supporting 99215. Document the drug and the monitoring.

Prolonged outpatient time

Past the top of the highest level, prolonged-service add-ons apply — but Medicare and CPT diverge:

• CPT / most commercial: 99417 — each additional 15 min, added to 99205/99215, starting once you pass the level's minimum time (75 min for 99205, 55 min for 99215).
• Medicare: G2212 — same idea, but the clock starts later (after the maximum time of the level: 89 min for 99205, 69 min for 99215). Do not report 99417 to Medicare.

Confirm the current thresholds and your payer's choice; this pair is a common audit target.

Teaching physician rules & learners charting

In an academic clinic the chart may be touched by a fellow, a resident, or a medical/APP student before you sign. Each has different documentation rules. Pulmonary fellows are residents for Medicare teaching-physician (TP) purposes — they fall under TP rules, not split/shared.

Residents & fellows — Teaching Physician (TP) rules

• The service is billed under the teaching physician. The TP must personally see the patient and personally perform (or be present for) the portion of the service that determines the level.
• If leveling by MDM: the TP may verify the resident's documentation (history, exam, MDM) rather than re-document it, but must personally participate in management and indicate that in the note.
• If leveling by time: only the teaching physician's time (alone, or with the resident together) counts. Resident-alone time does not count — a key contrast with APP split/shared, where both clinicians' time combines.
• Append modifier GC when a resident/fellow participated.

Medical / PA / NP students

• Since 2018, the TP (or the resident) may verify any student-documented component — ROS, PMH/social/family history, HPI, and exam — and need not re-document it.
• But the TP must personally perform (or re-perform) the exam and the MDM and personally verify what the student wrote. Student documentation can support, not substitute for, the billable work.

The Primary Care Exception — usually NOT your clinic

At approved primary-care centers, the Primary Care Exception (PCE) lets the TP bill certain lower/mid-level visits (99202–99204, 99212–99214 and select preventive codes) without being present for the key portion, using modifier GE. A subspecialty pulmonary clinic generally does not qualify — assume standard TP presence rules apply and use GC, not GE, unless your GME/compliance office has specifically designated the site.

Quick decision guide

Medicare rules; teaching-physician documentation policy is in the Medicare Claims Processing Manual ch. 12 §100. Commercial payers may differ.

APPs — incident-to vs split/shared

For NPs and PAs, the right rule depends entirely on where the clinic sits. Getting this wrong is both a payment error and a compliance risk.

Freestanding office (POS 11) — incident-to is possible

• An APP's service can bill under the physician's NPI at 100% if all incident-to conditions are met: the physician initiated care and set the plan, the patient is established with an established problem, the physician provides direct supervision (present in the office suite, immediately available), and the encounter is an integral part of the plan.
• New patients and new problems cannot be incident-to. Those bill under the APP's own NPI at 85%.

Provider-based / hospital outpatient clinic — incident-to does NOT apply

• In the facility setting, incident-to is unavailable. Either the APP bills under their own NPI (~85%), or — when a physician and APP in the same group both personally perform part of the same visit on the same day — split/shared rules apply.
• Split/shared: the clinician who performs the substantive portion bills. For visits leveled by time, substantive = >50% of the combined time; for visits leveled by MDM, substantive = performed the MDM (confirm the current year's definition — CMS has shifted it). Append modifier FS.

Document both individuals by name, each one's role/time, and who did the substantive portion. The billing clinician signs and dates.

Telehealth — Ohio-specific

Pulmonary is well-suited to telehealth for the right visits — PAP/CPAP adherence, stable ILD / PAH / sarcoidosis follow-up, post-discharge COPD checks, biologic-therapy management, tobacco cessation — while PFTs and exam-dependent encounters still need an in-person slot. Three layers of rules stack here: Medicare, the CPT code set, and Ohio (Medicaid + the state standard-of-care statute).

Volatility warning. Medicare's telehealth flexibilities have repeatedly approached a “cliff” and been extended at the last minute (most recently they lapsed 31 Jan 2026, then the Consolidated Appropriations Act, 2026 — signed 3 Feb 2026 — restored and extended them). Confirm the current expiration date and your MAC's guidance before relying on any item here.

1) Medicare (as extended for 2026)

• No geographic restriction; the patient's home is an eligible originating site for non-behavioral telehealth — extended through Dec 31, 2027.
• Audio-only is permitted for non-behavioral telehealth through Dec 31, 2027 (when the patient can't or won't use video). Behavioral/mental-health visits keep their own in-person-waiver track (through Jan 1, 2028).
• Coding for Medicare: report the usual office E/M (99202–99215) with POS 10 (telehealth, patient at home) or POS 02 (telehealth, location other than home), plus modifier 95 (synchronous audio-video) or 93 (audio-only).
• Medicare does NOT accept the new 98000–98015 telemedicine codes — it kept the office-E/M-plus-modifier approach. It does recognize 98016 (brief virtual check-in).

2) The CPT telemedicine codes (CY2025+) — for non-Medicare payers

• AMA added a dedicated series that replaced the deleted telephone codes 99441–99443: 98000–98007 synchronous audio-video, 98008–98015 synchronous audio-only, and 98016 brief synchronous check-in (5–10 min).
• Some commercial and Medicaid plans want these codes; Medicare wants the office E/M + modifier 95/93 instead. Check each payer.

3) Ohio

• Ohio Medicaid — OAC 5160-1-18 (in effect since 15 Jul 2022): telehealth means synchronous real-time audio + video (plus defined asynchronous activities). No geographic restriction — the patient can be anywhere, including home. Note ODM has not adopted modifier 93 for audio-only; follow ODM's current billing guidelines for how it wants audio-only and the 98000-series reported.
• Ohio standard-of-care statute — ORC 4743.09 (from HB 122, effective 23 Mar 2022): the standard of care via telehealth must equal in-person care, and a provider–patient relationship may be established by telehealth (synchronous or asynchronous) if that standard is met. Implemented across the licensing boards (e.g., State Medical Board rules, OAC 4731-37-01).
• Licensure follows the patient. You must be licensed in the state where the patient is physically located at the time of service — relevant for a referral region that crosses into KY/WV/IN/PA/MI. The Interstate Medical Licensure Compact can speed multistate licensure.

When the provider-based clinic hosts the patient end of a telehealth visit, the hospital may bill the originating-site facility fee Q3014. Always document the patient's physical location and the modality (audio-video vs audio-only).

E-consults & virtual check-ins

Interprofessional consultation lets a pulmonologist weigh in on a case without a face-to-face visit — review the chart/imaging, render an opinion to the requesting clinician, and bill for the cognitive work. Common pulmonary e-consults: an incidental lung nodule, abnormal PFTs, chronic cough, pre-operative risk, or an abnormal chest CT.

Requirements that make these payable

• Patient consent documented (these carry cost-sharing) and the request documented in the record.
• You have not seen the patient in person in the prior 14 days, and the consult does not lead to a transfer or face-to-face visit within the next 14 days (otherwise bill the visit instead).
• For the timed verbal codes, >50% of the time is the medical consultative discussion/review; report your review + report time.

Related brief communication-technology services: G2012/98016 virtual check-in (5–10 min), and G2010 remote evaluation of patient-submitted images/video (e.g., a photo of a home spirometry trace or inhaler technique).

Pulmonary-fit E-consults shine for nodule triage and PFT interpretation, cutting wait times for a full visit; document consent, the question asked, your review, and your written recommendation.

E-visits — patient-portal / MyChart messages

Yes — billable. When a patient sends a message through the portal (MyChart) that needs real clinical work to answer, that asynchronous, patient-initiated exchange can be billed as an online digital E/M (“e-visit”). It is not for clerical or quick replies — it has to involve genuine evaluation and medical decision-making.

The guardrails that decide whether it's billable

• Patient-initiated and an established patient — you can't bill a message you started, and these aren't for new patients.
• Requires your medical decision-making. A refill done by protocol, a scheduling reply, or “your results look fine” with no decision doesn't qualify.
• Counts cumulative time over a 7-day period (all your portal work on the issue, including review and the response), reported once per 7 days.
• Bundling windows: not billable if it stems from an E/M in the prior 7 days (it's part of that visit's work); and if it leads to an office/telehealth visit within the next 7 days, the e-visit work rolls into that visit. Not billed on the same day as another E/M.
• Consent to possible cost-sharing is documented (commonly a one-time portal consent).

Pulmonary-fit Example: an established asthma/COPD patient messages about worsening dyspnea and peak-flow readings; you review the trend, adjust the inhaler regimen, and document the decision — that's an e-visit, not a free message. Clinical staff who can't independently bill E/M use the non-physician equivalents 98970–98972.

Remote monitoring — RPM & RTM

Two parallel families let you bill for managing device-transmitted data between visits. RPM covers physiologic data (pulse oximetry, home spirometry/peak flow, BP); RTM covers therapeutic data including the respiratory system (inhaler/PAP adherence, symptom logs).

Pulmonary-fit Home pulse-ox or peak-flow trending (RPM) and PAP/inhaler adherence (RTM 98976) fit chronic COPD, severe asthma, and post-discharge programs. Require patient consent, an established condition, and the monthly time/data thresholds; do not double-count the same time under another care-management code in the same month.

Transitional care — the post-discharge window

After a hospitalization (COPD or asthma exacerbation, pneumonia, PE), Transitional Care Management pays well for owning the 30-day transition. It requires an interactive contact within 2 business days of discharge and a face-to-face visit within a window set by complexity.

One TCM per beneficiary per 30-day period, billed at the end of the window. The 2-business-day contact can be by phone or portal (by clinical staff). Document the discharge date, the contact, medication reconciliation, and the face-to-face date. Strong fit for a post-exacerbation pulmonary follow-up.

Chronic & principal care management

Between visits, ongoing care coordination is billable monthly. CCM needs ≥2 chronic conditions; PCM is built for a single, complex, high-risk condition — which is exactly the subspecialty pulmonary situation (advanced COPD, severe persistent asthma, ILD, pulmonary hypertension).

Pulmonary-fit PCM (99424/99426) is the natural fit when one pulmonary condition drives the patient's risk — e.g., a PAH patient on parenteral prostacyclin, or severe COPD with frequent exacerbations — without needing a second qualifying chronic illness.

When to bill — and yes, it's the between-visit work

This is the point most often missed: CCM/PCM pays for the non-face-to-face care you do between office visits — medication management, reviewing home data and outside results, phone calls, refills, prior auths, and coordinating with the PCP, pharmacy, or home-infusion company. It is not a visit code and does not require the patient to be in the room.

• Billed once per calendar month, submitted at month-end once that month's time threshold is met — CCM 99490 ≥20 min clinical-staff time (or 99491 ≥30 min physician/QHP); PCM 99424 ≥30 min physician/QHP (or 99426 ≥30 min clinical staff). Time is cumulative across the month; add-on codes capture each additional increment.
• No double-counting. Minutes already counted toward a billed E/M, TCM, the same month's other care-management code, or RPM/RTM management time can't also be counted here.
• One practitioner per patient per month. A patient can't be billed CCM and PCM in the same month by the same practitioner — coordinate with primary care so you're not duplicating (often pulmonary bills PCM for the lung condition while PCP handles overall CCM, but only one care-management code pays per month).

Documentation needed to bill

• Patient consent — obtained once (until they change practitioner), documented in the record, noting that cost-sharing applies, that only one practitioner bills per month, and that they may stop anytime.
• A care plan in the EHR — comprehensive (CCM) or condition-specific (PCM), shared with the patient and revised over time.
• A time log of the month's care-coordination activities (who, what, minutes).
• The qualifying condition(s) — CCM: ≥2 chronic conditions expected to last ≥12 months (or until death) placing the patient at significant risk; PCM: one complex condition expected to last ≥3 months with frequent medication/regimen adjustment.
• 24/7 access to the care team and continuity of care arrangement.

Advance care planning & tobacco cessation

Advance care planning (ACP)

Goals-of-care conversations are billable and clinically central in advanced ILD, end-stage COPD, and PAH.

Time-based; document the discussion (no completed directive required). May be reported same day as an E/M with the time carved out; Medicare waives cost-sharing when furnished with the Annual Wellness Visit.

Tobacco / nicotine cessation counseling

Separately reportable with an E/M (carve the counseling minutes out of E/M time and append -25 to the E/M). Document minutes and content. Vaping/e-cigarette counseling is captured here as well.

PFTs & pulmonary diagnostics — and the component split

The defining academic-clinic billing question for diagnostics: who owns the equipment? Each test has a technical component (running it) and a professional component (interpreting it). In a provider-based pulmonary lab the hospital bills the technical side (-TC) under OPPS and the physician bills only the interpretation (-26). In a freestanding office that owns the equipment, you bill the global code (no modifier).

Two recurring traps. (1) In a provider-based lab, don't bill the global code — bill -26 only, or you'll be denied/recouped for the technical component the hospital already billed. (2) When you also perform a significant E/M the same day, append -25 to the E/M or the visit gets bundled into the PFT.

How to read the dollars: these are approximate national global (non-facility) amounts (CY2026 CF $33.40). A provider-based lab bills the professional component (-26) only — a fraction of the global — while the hospital bills the technical side. wRVUs are the small professional-component work values (≈0 for purely technical tests like nebulizer 94640/94664). * Flow-volume loop (94375) is bundled into spirometry; ABG (82803) pays on the clinical lab fee schedule, not the PFS; HAST coverage/payment is MAC-variable. Pulse oximetry (94760/94761) is generally bundled into the E/M. DLCO (94729) is an add-on. CPET (94621) bundles its component services (ECG, oximetry, spirometric parameters, VO₂/VCO₂) — don't unbundle them. Verify each code's component eligibility, payment, and NCCI edits on the CMS PFS Look-Up Tool.

Infusions, injections & biologics

The severe-asthma biologics and PAH therapies make drug administration a real revenue and documentation area. Two separate things are billed: the administration code (the act) and the drug itself (a HCPCS J-code, usually buy-and-bill).

Administration hierarchy — one “initial” per encounter

Report only one “initial” code per encounter per IV access, and the “initial” is the primary reason for the encounter — not whatever happened to run first. Layer additional-hour / sequential / concurrent codes on top. Carve administration time out of any E/M time.

Administration codes carry tiny work RVUs — the payment is almost entirely practice expense, so the dollar amount swings sharply between office (non-facility) and provider-based (facility, where the hospital bills the facility fee). The drug is paid separately from its J-code at roughly ASP + 6% (buy-and-bill); that drug payment, not the administration code, is where the dollars are.

Common pulmonary agents

Bill the drug separately with its HCPCS J-code and document drug, dose, and units administered, plus wastage: append JW for the discarded amount of a single-dose vial, or JZ to attest no wastage. Pulmonary-fit Most asthma biologics are subcutaneous (96372); reslizumab and IVIG are IV infusions. Provider-based status materially changes infusion economics (facility fee + drug handling).

If a significant, separately identifiable E/M (e.g., the assessment deciding to continue/adjust the biologic) is done the same day, append -25 to the E/M. J-codes update frequently — verify the current HCPCS before billing.

Pulmonary rehab & sleep

Pulmonary rehabilitation

Coverage typically targets moderate-to-very-severe COPD (and other qualifying diagnoses); document the qualifying diagnosis, the individualized treatment plan, and per-session components. G0424 is the hospital-based (provider-based) route; 94625/94626 are the physician-practice codes (added 2022).

Sleep

Sleep studies also split into professional (-26) and technical components in a provider-based lab. Document the indication, AHI/RDI, and titration outcome; OSA follow-up and PAP adherence visits are ordinary office E/M (and good telehealth candidates).

Clinic modifiers that matter

Sources & caveats

• Professional RVU/$ figures use CY2026 Medicare PFS values (conversion factor $33.40); national, unadjusted, and (for E/M) approximate non-facility. Confirm individual codes against the CMS PFS Look-Up Tool; provider-based clinics pay the lower facility rate.
• Office/outpatient E/M leveling, MDM, and prolonged-service rules per the AMA CPT 2021+ E/M framework and CMS (99417 vs Medicare G2212). Teaching-physician documentation per the Medicare Claims Processing Manual ch. 12 §100; incident-to and split/shared per CMS/MLN — substantive-portion definitions have shifted year to year.
• Telehealth is volatile. Medicare flexibilities lapsed 31 Jan 2026 and were restored/extended (non-behavioral through 31 Dec 2027; behavioral in-person waiver through 1 Jan 2028) by the Consolidated Appropriations Act, 2026. Re-verify the current expiration and your MAC's guidance before billing. Medicare uses office E/M + modifier 95/93; it does not accept CPT 98000–98015 (but recognizes 98016).
• Ohio Medicaid telehealth per OAC 5160-1-18 (effective 15 Jul 2022) and the current ODM Telehealth Billing Guidelines; Ohio's telehealth standard-of-care statute is ORC 4743.09 (HB 122, effective 23 Mar 2022), implemented through the licensing boards (e.g., State Medical Board OAC 4731-37-01). Licensure follows the patient's location.
• Interprofessional consult (99446–99452), online digital E/M / e-visits (99421–99423; non-QHP 98970–98972), care-management (TCM/CCM/PCM), ACP, remote monitoring (RPM/RTM), drug-administration, and PFT codes (incl. CPET 94621 and HAST 94452/94453) per AMA CPT and CMS guidance. Care-management $ are national monthly averages (~2025–26); RPM/RTM and small-wRVU procedure dollars are practice-expense-driven and site-dependent. CPT telemedicine codes 98000–98016 added CY2025. HCPCS J-codes update frequently.
• This is an educational documentation-improvement reference — not coding, legal, or financial advice, and not an official CMS, AMA, or Ohio product. CPT® is a registered trademark of the AMA. Final code assignment rests with certified coders/CDI and your compliance team.

Built as a static reference site, companion to the Critical Care (ICU) page. Professional values current as of CY2026 Medicare rules; telehealth status as of early 2026. Re-verify at the next PFS / CPT update and whenever the telehealth extension date approaches.