Pulmonology Coding Alert

When your pulmonologist records critical care time with multiple procedures, don't stop at critical care codes, because your billing may require more specificity.

Here's the second segment of a three-part series that focuses on a patient who undergoes multiple bronchoscopies. Please refer to the July 2005 Pulmonology Coding Alert for " Case Study, Part I: Avoid Common Coding Snafus for Multiple Bronchoscopies."

Take a Look at the Operative Report

After the initial bronchoscopies and trying to remove the mucus plugs, the pulmonologist continued to have the same problem. At this point, the pulmonologist noted three hours of critical care time. The endotracheal tube still seemed to be kinked against the tracheal wall.

The pulmonologist then examined the patient's vocal chords with a straight laryngoscope. At that time, the pulmonologist discovered that the cuff was sitting between the patient's vocal chords and that the endotracheal tube was kinked upward into the vocal chords. The pulmonologist then straightened the tube and advanced it downward again.

The pulmonologist performed a bronchoscopy, and he passed the endotracheal tube into the right, main bronchus. After that, the pulmonologist completed multiple bronchoscopies because he was able to proceed downward to the lower end of the endotracheal tube without any resistance, and the lower end of the patient's trachea was open without any resistance.

At this time, the pulmonologist reattempted to use the bronchoscope to suction out mucus plugs from the patient's left bronchus. He had some success but notes that the patient's left main bronchus still had significant long, stringy, thick mucus plugs. After multiple attempts to suction these plugs, the pulmonologist ended the procedure.

After the pulmonologist adjusted the endotracheal tube and performed another bronchoscopy on the patient, the patient's pulse oximetry rose to 92 percent. The pulmonologist expects the pulse oximetry to continue to rise.

The patient will continue to receive physical therapy and Mucomyst. The pulmonologist will have to attempt another bronchoscopy on this patient at a later time.

Critical Care May Not Be What You Expect

As mentioned in Part I of this case study, because the pulmonologist performs a second bronchoscopy to remove the mucus plugging, you should report a therapeutic bronchoscopy, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Given the above documentation, you should report 31646 (Bronchoscopy [rigid or flexible]; with therapeutic aspiration of tracheobronchial tree, subsequent).

Don't miss: The pulmonologist performed the second bronchoscopy (31646) on the same day.

NCCI considers 31645 (... with therapeutic aspiration of tracheobronchial tree, initial) and 31646 as mutually exclusive codes. This means that a pulmonologist would perform these two services on the same day. NCCI assigns modifier "1" to this code pair, allowing you to report the two services together, when appropriate. 

In such a case, you should add modifier 59 (Distinct procedural service), Pohlig says, to notify the payer that the pulmonologist performed a distinct service separate from the previous diagnostic bronchoscopy performed on the same day.

In addition to the procedure code, you should also report diagnosis code 519.1 (Other diseases of trachea and bronchus, not elsewhere classified) to represent the "mucus plug" identified in the documentation.
 
Know the critical care criteria: Although the documentation presents a total of three hours of critical care time, before you start reporting critical care codes make sure you know the rules for procedure coding and diagnosis coding, says Beverly Ramsey, CMA, CPC, CHCC, CHBC, at Doctors Management in Asheville, N.C.

CPT defines a critical illness or injury as one that impairs one or more vital organ systems, creating a high probability of imminent or life-threatening deterioration in the patient's condition.

Therefore, if the patient appears to have a life-threatening condition that affects one or more of the patient's vital organ systems (e.g., respiratory distress), and the physician provides direct medical care, you should report critical care services, Ramsey says.

The bottom line: In this scenario, although the patient does appear to meet the above criteria, the total critical care time also includes the time associated with the separately billable procedures. Therefore, the documentation presented here does not justify reporting critical care codes.
  
Note: The operative note was reviewed by Denae M. Merrill, CPC, a pulmonology coder in Saginaw, Mich.