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Pulmonology Coding Alert

Choose Different Codes for Arterial and Pulmonary Systems

Published on Tue Jan 01, 2002

Thromboembolic disease, a tendency toward blood clotting in the arterial system, is most commonly diagnosed as deep venous thrombosis (DVT) or a blood clot in the leg using 451.11 (phlebitis and thrombophlebitis; of deep vessels of lower extremities) or 451.19 ( other).
 
Pulmonary embolic disease, similar to thrombo-embolic disease but occurring in the pulmonary system rather than the arterial system, requires codes different from those used to report thromboembolic disease.
 
Coders must take great care to distinguish diagnosis codes that apply to the arterial system from those that apply to the pulmonary system. For example, a pulmonologist examining a patient who presents for a pulmonary embolism may not find emboli in the lung area. "Many times when we go looking for emboli in the lungs, we find it in the legs," says Charlie Strange, FCCP, of the department of pulmonary medicine at the medical university of South Carolina. "A doctor may be called in for chest pain, but didn't identify emboli in the lung and instead finds clots in the leg. So, even though the patient may have had a pulmonary embolism, the only evidence is DVT, which utilizes diagnosis codes 451.11 to 451.19."
 
Pulmonologists will report "pulmonary embolism" as their primary diagnosis because that is the condition they are treating, with DVT being the underlying condition.

Typical Diagnostics for DVT and PE

Many symptoms characterize thromboembolic disease, some of which can impact the pulmonary area. A patient who presents with acute shortness of breath, chest pain, dizziness and coughing up blood is diagnosed with a pulmonary embolism (PE) using 415.11-415.19. Extensive tests are required before the physician can reach a primary diagnosis of DVT or PE and begin a regimen of coagulation therapy to stabilize the patient and reduce the risk of further clotting. The physician cannot bill for the combination drug therapy, because a hospital would administer it on an inpatient basis or a nurse would administer it once the patient is released.
 
The physician can only bill for services that he or she has rendered. For example, a physician can bill for an x-ray if it was performed and interpreted in his or her office. Use a code from the series 71010 (radiologic examination, chest; single view, frontal) to 71035 (radiologic examination, chest, special views [e.g., lateral decubitus, Bucky studies]).
 
However, a physician who suspects a pulmonary embolism typically orders an x-ray, ventilation perfusion lung scan or spiral CT scan with contrast to look for lung defects, or a pulmonary arteriogram to look for emboli in pulmonary arteries, venous plethysmography (non-invasive screening vascular study to identify a blood clot), or a venogram that injects dye in the venous system if noninvasive studies are inconclusive. Pulmonologists cannot bill for any of these services because they do not perform them.

Physician's Role Dictates Billing Codes

A doctor bills for his or her E/M services for pulmonary embolic disease based on whether he or she is an admitting physician or a consulting physician and whether the patient was diagnosed during an in-office visit, at the emergency room, or was admitted to the hospital. An admitting physician would bill 99221-99223 (initial hospital care, new or established patient) for the initial admission of the patient. Conversely, a consulting physician would bill 99251-99255 (initial inpatient consultations, new or established patient) for a patient in the inpatient setting. Coders must also take care when billing for an attending physician's services for a patient's hospital admission.
 
"If the admitting physician sees the patient in the office and admits the patient to the hospital on the same day, only one service can be reported and that would be the initial admission service," says Carol Pohlig, BSN, RN, CPC, of the department of medicine at the Hospital of the University of Pennsylvania. Also, if a patient comes into the emergency room and the ED physician determines the patient should be admitted, the hospital bills the admission or DRG code. It is then that the hospital calls the pulmonologist in as a consult, and he or she bills inpatient consultation codes 99251-99255.     

But if the patient is admitted to the hospital from the emergency room by the pulmonologist, 99221-99223 would be used.
 
Note: The level of E/M service is based on six required elements: history, examination, medical decision-making, counseling/coordination of care, nature of presenting problem, and time. History, examination and medical decision-making are considered key components. If counseling/coordination of care dominates the visit (more than 50 percent), then the nature of presenting problem and time may assist. 

Coding Different Patient Scenarios

Thromboembolic disease scenarios and codes are listed below, based on the type of service rendered by the physician and whether the physician is treating an established patient or is brought in to consult.
 
Codes 99241-99245 are outpatient consultation codes, and 99201-99205 are for patients who are outpatient but new to the primary physician. Codes 99211-99215 are for patients who are established or have seen the primary physician within three years.
 
Professional services rendered by the physician usually begin with an inpatient consultation (99251-99255). If the pulmonologist continues to see the patient, he or she would use 99231-99233 (subsequent hospital care) for subsequent days of the patient's stay in the hospital. If the patient is critically ill and the care provided fulfills the requirement, critical care codes 99291-99292 apply.
 
Once the patient is released and has been placed on a treatment regimen, certain codes apply for professional services in the long-term management of the patient. The codes can vary from low-level with a nurse check (99291) to a high-level office visit if the physician examines the patient and documents the level of service (99215).

Be as Specific as Possible

Physicians often change the diagnosis of hospital patients daily, with a specific diagnosis code used for each day of service based on the patient's condition. Each E/M service is billed separately, and reimbursement varies with the level of service selected.
 
The level that the doctor bills depends on the type of documentation to support the work performed and the information maintained in the medical record. And, up to four diagnosis codes may be provided for each encounter under CMS regulations. The first diagnosis should be the primary diagnosis to justify the service.
 

If a patient is diagnosed with PE and has shortness of breath, chest pain and another comorbid condition like coronary artery disease, the PE would be coded 415.19 (as the primary diagnosis) with secondary codes of 786.05 (shortness of breath), 786.5 (chest pain), and 414.0x (coronary artery disease).

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