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Pulmonology Coding Alert

Case Study:

Tuberculosis: An Age-Old Health Threat Poses Reimbursement Challenges

Published on Fri Feb 01, 2002

Tuberculosis (TB) is a growing health threat nationwide and a problem seen by pulmonary physicians with increasing frequency. The patient who presents with a cough (786.2), weight loss (783.21) and intermittent fever (780.6) must be evaluated carefully to rule out TB along with any number of other conditions, including malignancy and HIV. TB is, however, a common co-infection seen in people who have HIV.
 
The following case study highlights some of the challenges practices will encounter in diagnosing and coding for the patient with TB.

Initial Referral

A primary care physician (PCP) refers a 66-year-old man with Medicare Part A and B coverage to the pulmonologist for evaluation of a chronic cough and an unintended 10-pound weight loss. The patient appears unwell: pale, with a resting respiratory rate of 28. His last purified protein derivative (PPD) skin test for TB at the public health clinic was negative.
 
On the first consultative visit (99241-99245), the pulmonologist reviews the patient's lengthy medical records and most recent chest x-ray, which shows a fibronodular infiltrate in the right upper lung. Next, an extensive history and physical are performed. The patient admits to multiple sexual encounters, but denies intravenous drug use. The pulmonologist orders a complete blood count, which the hospital lab used by the pulmonology practice reports as showing a slight iron-deficiency anemia (280.9) and a mild leukocytosis (288.8).
 
The nurse administers a repeat skin PPD and performs venipuncture to obtain blood samples for histoplasmosis and HIV, which are sent to a regional clinical pathology lab. The patient is rescheduled for a follow-up visit in one week to review the test results and undergo a more extensive diagnostic workup. The patient is referred to the radiology clinic for a repeat chest x-ray after the visit.

Billing the Initial Consultation

The initial consult is billed using E/M codes for consultation (99241-99245), which includes the three key components history, exam and medical decision-making. The pulmonologist chooses to code 99245 due to the comprehensive history and exam, the lengthy medical-record documentation that he reviewed, and the complexity of the diagnostic workup required to confirm the diagnosis.
 
The pulmonologist documents in the progress notes that he or she "reviewed the report" and/or "personally viewed the films." The histoplasmosis and HIV would be billed to Medicare by the lab analyzing the specimen, which submits the CPT code to Medicare and is paid under the Laboratory Fee Schedule, not the Physician Fee Schedule. However, the pulmonologist should provide the appropriate diagnosis coding with the lab order (either the reason for the test or the visit) so the lab can get paid. In this case, the ICD-9 codes supporting medical necessity of the lab tests are cough (786.2), weight loss (783.21) and intermittent fever (780.6).
 
Payment for the venipuncture to obtain specimens for histoplasmosis and HIV is billed using G0001 (routine venipuncture for collection of specimen[s]) with the E/M code. If a histoplasmosis skin test is given, use 86510 (skin test; histoplasmosis). However, the blood test is more accurate for diagnostic purposes.

Bill for Placement of Skin Testing Only

The PPD can be reported with 86580 (skin test; tuberculosis, intradermal) but only when the skin test is performed, says Teresa Thompson, CPC, a coding and reimbursement specialist in Sequim, Wash. "When the patient returns for the reading, do not bill 86580 again," she says. Nor do you bill for another office visit if the only service that occurs during that visit is the PPD reading.
 
"If the patient returns to the office, has the PPD read, and requires an E/M service for counseling or to institute treatment, or for a different problem, then the visit should be coded with the appropriate diagnosis and E/M code for the service provided," says Mary Mulholland, RN, BSN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia.
 
Billing Sputum Collection for Smears, Culture

The patient returns with his wife for the follow-up visit to the pulmonologist's office. The office nurse reads his PPD as normal. The lab has also reported a negative reading on the histoplasmosis and HIV tests. 
 
The pulmonologist reads the chest x-ray, which shows progression of the infiltrate in the right upper lung. Next, the nurse obtains sputum for smears and culture, to be performed by a regional microbiology commercial lab. "The CPT code for aerosol inhalation for inducing sputum to obtain the sample is 94664 (aerosol or vapor inhala-tions for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes), and subsequent procedures (on different days of service) to obtain sputum are coded 94665 (... subsequent)," says Cynthia DeVries, RN, CPC, coding and reimbursement specialist with Lee Physicians in Fort Myers, Fla. If the aerosol treatment is not used to induce sputum production, then there is no additional payment for obtaining the specimen.
 
The pulmonologist spends 35 minutes with the patient reviewing the test results, including the x-ray, PPD and HIV testing. The nurse also spends 20 minutes counseling the patient privately about high-risk behaviors for HIV.
 
This follow-up visit could be billed as an established patient visit, 99211-99215. The physician counseling (35 minutes) warrants 99214. If the total documented visit time with the physician is at least 40 minutes, bill 99215. The nurse's time counseling the patient about HIV does not count for billing.

Bronchoscopy Is the Next Step

After three sputum samples have been obtained on different days, the lab reports the sputa as negative. Given the patient's symptoms, history and x-ray, however, the pulmonologist schedules the patient for an outpatient bronchoscopy with direct washings the next morning.
 
"To bill the bronchoscopy, the pulmonary physician reports 31622 (diagnostic bronchoscopy)," Mulholland says. This code tells the carrier that a diagnostic bronchoscopy was performed.
 
The bronchoscopy confirms TB through microscopy examination of the specimens obtained by the procedure. The diagnosis code for the procedure is 011.13 (tuberculosis of lung, nodular, tubercle bacilli found in sputum by microscopy). The fourth digit specifies the location and type of pulmonary TB. The fifth digit tells how the TB was diagnosed.
 
The pulmonologist prescribes Rifater for the patient, which is a combination of isoniazid, rifampin and pyrazinamide. He also orders a chest x-ray and PPD testing for the patient's wife. The diagnosis code to bill for the PPD testing is V01.1 (contact with or exposure to TB).

Billing Two Visits in the Same Day

The pulmonologist schedules a follow-up visit in one month for repeat sputum cultures and x-ray and to assess medication compliance and side effects. Within two weeks, however, the patient is seen by the pulmonologist for complaints of loss of appetite (783.0) and general malaise (780.79). A stat liver panel obtained by the pulmonologist's office reveals normal hepatic enzymes.
 
The pulmonologist counsels the patient that the symptoms are probably side effects of the medication, stressing the importance of taking the medication as directed. The pulmonologist may use an E code, which explains external causes of injuries. To code the adverse effect of the medication, use E931.8 (other antimycobacterial drugs) as a secondary diagnosis to the symptom codes (e.g., 783.0 and 780.79) to represent fully the patient's problem.
 
That evening, the patient appears unannounced in the pulmonologist's office with a fever of 101 degrees, aches and chills. The doctor listens to his chest, which is clear, and orders a stat white blood count, which shows leukopenia (288.0) all of which suggest a viral syndrome. The pulmonologist diagnoses influenza (487.1) and tells him to take ibuprofen every four to six hours for symptom relief.
 
There are a couple of options for billing these visits on the same day. The visits could be combined and reported as an established patient visit, most likely 99214 or 99215 with 99354 (prolonged physician service) if the additional visit is more than 30 minutes. (See the sidebar on page 11, "Coding the Prolonged Visit.")
 
According to the Medicare Carriers Manual, however, the physician may bill for two visits on the same day if the second visit is separately identifiable from the first, which, in this case, it is. In such a situation, the physician bills 99214 (about $80) or 99215 (about $125) for the first visit and 99213 (about $50) for the second visit. Modifier -59 (distinct procedural service) is appended to the second visit to indicate different procedures performed on the same day for different diagnoses. "The pulmonologist should attach a paper claim with documentation to support the medical necessity of the two visits," DeVries says.
 
Choosing the first option, however, will avoid a denial. The physician will most likely receive higher reimbursement for the second visit if he or she rolls the visits into one and bills for prolonged care, using 99214 or 99215 with 99354 (about $120), as mentioned above.

Noncompliance with Medication Regimen

At the next monthly follow-up visit, the pulmonologist obtains repeat sputum samples and another x-ray. The patient's wife informs the pulmonologist privately that her husband is not taking all of his medication.
 
The pulmonologist spends 30 minutes talking to the patient, assessing why he is not taking the medication and counseling him on the risks of noncompliance. Unconvinced that the patient will take the medication correctly, the pulmonologist confers with the local public health department physician for 25 minutes via phone about enrolling the patient in an incentive program that has improved medication compliance in people who have TB or HIV.
 
"In billing for counseling of the patient for noncompliance with medication regimens, use 99214 for 30 minutes of counseling the established patient," DeVries says. The pulmonologist may only bill for the phone consultation time if it is done in the presence of the patient, which it was not in this case, due to the sensitive nature of the material discussed.
 
If the patient was present during the phone consultation, the physician would most likely incorporate the phone time into his or her counseling and coordination of care time. "If the physician were not billing based on time, then he or she may use the phone conversation to contribute to the complexity of the medical decision-making," Mulholland says. "The physician submitting a claim for the consult must still adhere to all of the documentation guidelines associated with submitting a claim for a consult, e.g., send a letter to the requesting physician, etc."

Patient Referred to Incentive Program

The pulmonologist refers the patient to the TB clinic for its incentive medication program and schedules a follow-up office visit with the patient in two weeks to re-evaluate compliance.
 
In coding for the visit to address the patient's noncompliance with his medication regimen, the pulmonologist faces a difficult decision. The ICD-9 code for this visit is V15.81 (noncompliance with medical treatment), which can have serious implications for the patient's insurance profile, as it poses this patient as a more serious health risk with increased potential for hospitalizations because he is not complying with preventive measures.
 
Because the patient in this case is not intentionally refusing to take the medication, one alternative to V15.81 is to code the patient's medical diagnosis (TB) in addition to V58.69 (current long-term use of high-risk medi-cations) to report the medical necessity for the visit or services provided.

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