Pulmonology Coding Alert

If you're submitting a claim for cystic fibrosis (CF) treatment without understanding fully how you should report it, you risk a denial.

When your pulmonologist treats patients diagnosed with CF, he will possibly prescribe exercise, antibiotics, bronchodilator therapy, mucolytic therapy, airway-clearing methods/devices, and chest physical therapy (CPT). Avoid unnecessary setbacks and let these three hints help you map out your strategies in reporting the diagnosis and treatment of CF patients.

Background: Cystic fibrosis is an inherited disease that causes the mucus lining the mucosal surfaces of internal organs to become thick, dry, and sticky. This denser mucus (secretions) in the lungs gives bacteria a uniquely favorable place to grow, making CF patients more susceptible to more strains of bacteria than other people. CPT, as a treatment, helps to remove the secretions from the lung to the upper airways where it can be coughed out.

First of all, a CF diagnosis includes different ICD-9 codes (277.00-277.09).

Suppose an ordering physician orders a direct sputum acid-fast stain and culture for mycobacteria for a patient with CF showing pulmonary exacerbation. Which diagnosis code should you report?

Consider that many CF patients develop pneumonia, so you should use a cystic fibrosis diagnosis code that extends to the fifth digit. In this case, use 277.02 (Cystic fibrosis with pulmonary manifestations) since the physician clearly stated "pulmonary exacerbation" in the narrative description.

Pulmonologists are frequently asked to evaluate and monitor the pulmonary manifestations of CF in the hospital setting. The pulmonologists may order tests, such as pirometry (94010-94070), chest x-rays (71010, Radiologic examination, chest; single view, frontal) and sputum smears/cultures (88160, Cytopathology, smears, any other source; screening and interpretation), in order to determine the patient's progress throughout the course of the hospitalization. They also work in concert with the primary physician to coordinate and analyze the treatment, and to address any further pulmonary problems which may occur.

Watch for: It is rare that a pulmonologist owns the x-ray equipment used for imaging in the outpatient setting. If the equipment is physician-owned and then used in a private office setting, you can bill for the x-ray using radiologic examination codes (71010-71035). Often, a pulmonologist sends the patient to an outside facility to get the x-rays done. You should then factor your pulmonologist's review of the x-ray results into the medical decisionmaking portion of the E/M service (99201-99215, Office or other outpatient visit...) provided to the patient.

Remember: The pulmonologist will focus on three main goals when treating CF: slowing lung damage with therapy, improving breathing by loosening and thinning mucus, and preventing or reducing lung infections. Consequently, the five specific treatments that pulmonologists utilize which make these goals more achievable include:

(1) medications, particularly antibiotics, to help manage lung infections;

(2) bronchodilators to help open the airways in the bronchial tree;

(3) mucolytics and inhaled hypertonic saline to help thin mucus;

(4) bronchial alveolar lavage occasionally (31624, Bronchoscopy [rigid or flexible]; with bronchial alveolar lavage to help clear away excess mucus; and

(5) chest physical therapy (CPT) to assist the patient in clearing secretions (94667, Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation; 94668, Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent).

Your pulmonologist may order CPT to be performed in a variety of settings, including a critical care unit, a hospital room, nursing homes, outpatient clinics, and commonly in the patient's home.

A must: The provider -- a respiratory therapist, nurse, or physical therapist -- should not perform CPT unless there is an initial prescription from a pulmonologist. This prescription should identify the patient, list the diagnosis, describe the frequency of visits, and define the duration of the treatment regimen.

Make sure you meet the following guidelines to justify CPT treatment by a registered provider:

• There is a documented treatment plan to stabilize the patient's status.
• The patient's pulmonary condition is unstable.
• No caregiver, such as a family member, can commit to performing CPT on the patient on a regular basis (for example, parents working full time or patient living alone).

Example: A CF patient is given a prescription to receive CPT in the home. A pulmonologist, nurse, or respiratory therapist explains and demonstrates techniques such as breathing control, percussion, and vibration techniques. The patient or his caregiver performs the therapy under the health professional's observation to be sure it can be done correctly. You should report this initial evaluation and demonstration as 94667 (Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation).

Note: The use of a device such as a mechanical percussor or the VEST can be covered as Durable Medical Equipment (DME), and not reported as 94667 since the code is reserved for demonstration of techniques used for treatment. Instead, use the HCPCS code E0480 (Percussor, electric or pneumatic, home model), which would be report to DMERCs and not to Part B Contractors.

On the other hand, if your practice employs the CPT provider, you should bill your CPT provider's subsequent visit to a patient's home with 94668. Also, if a bronchodilator is administered by the provider, you can bill 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device]).

Quick fact: If a home health-employed physical therapist administered CPT, the home-health agency reports different codes: G0151 (Services of physical therapist in home health setting each 15 minutes), and S9131 (Physical therapy; in the home, per diem).