Pulmonology Coding Alert

Experts offer quick tips for reporting all services

If your pulmonologist treats patients with sarcoidosis (135), you know that coding all the services for this complex condition can be a real challenge. You have to know how to code the patient referral and assign correct ICD-9 codes for treatment services. To make the process easier, follow these three strategies offered by coding experts.

1. Report 99245 for the Initial Consult

Pulmonologists normally see a patient with sarcoidosis - a multisystem disorder with an unknown etiology that produces an inflammatory response causing granulomas in the lungs and other organs - following a referral from the patient's primary-care physician (PCP).

For instance, a patient's PCP suspects sarcoidosis when the patient complains of fatigue (780.79), cough (786.2) and shortness of breath (786.05). The PCP orders chest x-rays and requests your pulmonologist's opinion.

Your physician reviews the patient's major organ systems and finds that the patient has fatigue (780.7x), abdominal pain (789.0x) and diarrhea (787.91).

Also, your pulmonologist reviews the blood chemistry studies and the chest x-rays (71010, Radiologic examination, chest; single view, frontal) and finds mediastinal lymphadenopathy (785.6) or abnormal x-ray findings of the lung (793.1). The patient's comprehensive history reveals past liver disease (571.x), exposure to asbestos (V15.84), and occasional pleuritic pain (786.52).

Because your physician performed a comprehensive history and exam and engaged in high-complexity decision-making, you may use 99245 (Office consultation for a new or established patient ...), coding experts say. To support payment for the highest level of consultation, your pulmonologist's documentation should include notes of all work he or she performed, such as reviewing x-rays and taking a comprehensive history, and a report detailing his or her findings for the primary-care physician. Also, append modifier -26 (Professional component) to 71010 for your physician's interpretation of the x-ray films.

2. Assign ICD-9 Codes for Biopsy and Spirometry

Based on the findings, your pulmonologist may perform a lung biopsy to properly diagnosis the sarcoidosis, says Charlie Strange, MD, FCCP, director of the medical intensive care unit at the Medical University of South Carolina in Charleston.

For example, your pulmonologist uses bronchoscopy (31622, Bronchoscopy [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]) to inspect the lungs and to decide which airway to use to perform the biopsy. After inspection, your physician does a transbronchial lung biopsy (31628, ... with transbronchial lung biopsy, with or without fluoroscopic guidance) that same day. You cannot report both 31622 and 31628, because surgical procedure payment always includes diagnostic work. In this situation, you should report only 31628.

Also, prior to your physician's sarcoidosis diagnosis, you should link 786.05, 785.6, 780.79 and 793.1 to the biopsy (31628) to support medical necessity. Once your pulmonologist diagnoses the patient with sarcoidosis, you should use 135 (Sarcoidosis) and 517.8 (Lung involvement in other diseases classified elsewhere) for follow-up visits, Strange says.

To monitor the disease's activity and the patient's lung performance, your pulmonologist may use spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). Medicare carriers, such as Cahaba Government Benefit Administrators in Birmingham, Ala., require that you assign 135 and 517.8 to justify spirometry for sarcoidosis monitoring.

In addition to spirometry following a sarcoidosis diagnosis, Strange suggests that the patient receive an electrocardiogram (EKG) (93000, Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) to look for heart abnormalities and an ophthalmology exam to look for uveitis (364.0x), Strange says.

For the ophthalmology exam, your physician will refer the patient to an ophthalmologist. But your pulmonologist will most likely perform the EKG, Strange says. Sarcoidosis is difficult to code because of the many organs the disease can affect, he adds.

To properly report your pulmonologist's EKG work, you should assign 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). Again, you should list conditions 135 (Sarcoidosis) and 517.8 (Lung involvement in other diseases classified elsewhere) as medical justification.

3. Use Time to Choose Follow-Up Code
 
To discuss the disease's treatment and other factors, your pulmonologist will schedule a follow-up visit with the patient, says Lois Geist, MD, a pulmonologist with the University of Iowa Healthcare's department of internal medicine in Iowa City. For example, during the follow-up, your physician discusses with the patient the sarcoidosis diagnoses and prednisone therapy's risks and benefits. In addition, your physician explains that the disease frequently enters remission, which makes evaluating the prednisone's effectiveness difficult. In total, your physician spends 15 minutes counseling the patient. Overall, the visit lasts 25 minutes.

Your pulmonologist should prescribe prednisone (corticosteroid) (J7506) to treat the sarcoidosis, Strange says. Also, your physician may place the patient on additional medications, such as methotrexate (J9250), azathioprine (J7501) or a tumor necrosis factor (TNF) inhibitor, he adds.

Although an office visit's length normally doesn't dictate the service level that you should code, this time the visit does because your pulmonologist spent more than 50 percent of this time counseling the patient. And if your physician has properly documented the visit, including discussion details and time, you should report 99214 (Office or other outpatient visit ... established patient), coding experts say.

If, however, your pulmonologist places the patient on methotrexate, azathioprine or a TNF inhibitor, your physician may spend at least 40 minutes with the patient, so you could increase the level of the follow-up visit to 99215, coding experts say.

You could use a V code to support the decision-making complexity for follow-up visits. For instance, assign V58.69 (Long-term [current] use of other medications) in addition to 135 and 517.8 when your physician's patient returns for toxicity monitoring and other follow-up visits.