Pulmonology Coding Alert

The January Pulmonology Coding Alert cover article Avoid Fraud: Dont Confuse Lung Lavage With Bronchial Alveolar Lavage, stated that lung lavages differ from bronchial alveolar lavage and should be coded 32997 (total lung lavage [unilateral]). The article also noted that a total lung lavage is a unilateral procedure because if both lungs were to be lavaged, the patient would drown.

The statement is accurate, but could be misinterpreted. Using a device that closes the lung to be washed and keeps the other lung open for respiration, pulmonologists are able to lavage both lungs. But the lavage is performed, for obvious reasons (the patient would drown), one lung at a time. Walter J. ODonohue, MD, FCCP, FACP, a representative to the AMA CPT Advisory Committee for the American College of Chest Physicians (ACCP) and CPT/RUC Committee chair of the ACCP, points out that the procedure occurs unilaterally in the sense of one lung at a time but should include modifier -50 (bilateral procedure) attached to 32997 because although listed as unilateral, the process can be done on both lungs (bilateral).

Carol Pohlig, CPC, RN, a reimbursement analyst for the office of clinical documentation, department of medicine at the University of Pennsylvania in Philadelphia, finds her physicians take another approach to the procedure. The procedure could be performed on both lungs, but this usually does not occur on the same date of service. One lung can take up to six hours, depending on the extent of disease. The second lung usually is done within the next few days.

The global period for 32997 is zero. This means that if the second lavage is performed on a different date of service than the first, you should report 32997 again for the subsequent date of service. You also can add the -RT (right side) and -LT (left side) modifiers to the procedures on each date of service.

In addition, the reader question Thrombosis Embolic Disease on page 6 stated that pulmonologists should use 444.9 for an arterial embolism and thrombosis of unspecified artery. But if possible, the physician should specify the embolisms location. For example, you should use 444.1 for an arterial embolism and thrombosis of thoracic aorta if possible, instead of 444.9. A more specific diagnosis code always increases the chance of prompt reimbursement.

Again the statement is accurate, however, because the answer focused on 444.9 for an arterial embolism and embolism for an unspecified artery. Although this is possible, the more likely case for pulmonologists would be one of pulmonary embolism and peripheral thrombosis, a much more common circumstance. These would be coded 415.1 (pulmonary embolism and infarction) and 453.9 (thrombosis [vessel]). Depending on the patient record, other codes such as 415 (acute pulmonary heart disease) with the sub-code 415.1 (pulmonary embolism), and group 453 (other venous embolism and thrombosis), including sub-codes 453.8 (embolism and thrombosis of other specified veins) and 453.9 (embolism and thrombosis of unspecified site) might be more appropriate. Watch for details in the patients documentation and if unclear, train your physician on the differences.

Finally, in the reader question Spirometry on page 6, the answer stated that you can bill for only one of the spirometry procedures. The common code to use for the first test is 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). Use 94070 (prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics) for the post test.

You can bill for only one of the relevant spirometry procedures (94010, 94060 or 94070). Consider the 94010 as the basic test. When the physician wants to look at change over time based on some form of stress, however, you would use either 94060 (bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]) or 94070.

Whether you use 94060 or 94070 depends on what test was provided. If a drug (bronchodilator) was given, use 94060. If a challenge test was performed, code 94070, Pohlig clarifies.