Pulmonology Coding Alert

Include hematological findings to bolster claims for services.

When pulmonologist diagnoses a patient with Acute Chest Syndrome (ACS, 517.3), you will reap the best benefits if you not only know how to code the signs and symptoms but also such procedures as sputum analyses and bone scans. 

Background: In a typical situation, ACS patients present with sickle-cell disease (282.42, 282.6x) and a hematologist refers them to the pulmonologist. Make sure to accurately report the signs and symptoms commonly found among ACS patients to justify your pulmonologist’s services before he makes a confirmed acute chest syndrome diagnosis. 

Example: Your pulmonologist gets a referred sickle-cell patient from a hematologist after the patient complained of chest pain (786.5x), difficulty breathing (786.09), shortness of breath (786.05), rib wall tenderness (786.59) and fever (780.6x). The physician conducts a thorough examination, including the organ systems, and takes his comprehensive history. He asks for x-rays, and after interpreting them, finds new infiltrates on the lung (793.19, Pulmonary infiltrate NOS). 

The following three points will help smoothen your way for receiving the deserved reimbursement for ACS services:

1. Justify the Chest X-Rays With ACS Symptoms

Payers will pay for the x-ray interpretations depending on whether the pulmonologist or the radiologist will read the films. If your physician does not own the x-ray equipment and only interprets the x-ray, you will code 71010 (Radiologic examination, chest; single view, frontal) along with modifier 26 (Professional component). Otherwise, the radiologist may perform both the interpretative work together with the technical component and bill for it. Make sure to connect the above discussed signs and symptoms, such as chest pain (786.5x) and rib cage tenderness (786.59), to code 71010-26 for faster acceptance.You may also code 99245 (Office consultation for a new or established patient …) if the service encompasses high-complexity decision making performed by your pulmonologist along with the comprehensive history and exam. 

To justify your demand of payment for a high-complexity consultation, do include your pulmonologist’s documentation of all work he or she performed, such as examining all the body systems, as well as reporting findings to the hematologist, in addition to all the notes kept. 

Remember, if you want to report a consultation code, another physician must request a consultation, your pulmonologist should provide an evaluation and recommendations for treatment, and your physician must send a written report detailing his or her findings to the requesting physician. If the payer does not accept consultation codes, you will have to report a new (99201-99205) or established patient (99212-99215) visit code instead.

2. Fat Embolism Can Be Key

Experts in the field caution that it’s best to rely on signs-and-symptoms coding because even physicians have a hard time distinguishing between ACS and pneumonia (480.x) during an acute episode.

Fat embolism (958.1) is a common occurrence in ACS patients with sickle-cell disease, which helps the pulmonologist differentiate between acute chest syndrome and pneumonia. For example, the patient may have an injury to the lungs due to a fat embolism released from a bone necrosis (730.1x, Chronic osteomyelitis) that injures the patient’s bone. ACS patients with pulmonary fat embolisms usually complain of severe bone and chest pain.

To make an even more definitive differentiation between pneumonia and ACS, the pulmonologist will most probably conduct a bronchoscopy (31622-31656). In that case, you would support the procedure with ICD-9 codes 958.1 (Fat embolism), 786.5x (Chest pain) and 282.6x (Sickle-cell disease), among others.

Your physician may perform a bronchoscopy (31622, …[rigid or flexible]; diagnostic, with or without cell washing [separate procedure]) to inspect the patient’s lungs. If, for example, he finds fat in the patient’s lungs (958.1), he will next perform a flexible bronchoscopy with bronchial alveolar lavage (31624, … rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage), and then definitively diagnose the patient with ACS.

In this case, you should connect the bronchoscopy procedure 31624 to 958.1, 730.1x and 786.5x. Remember that you cannot report 31622 separately because CPT® bundles that code into 31624.

3. Include Oxygen Therapy in E/M Service

Pulmonologists use oxygen therapy extensively to treat ACS. However, you can’t report a code for this service even if your physician administers oxygen to the ACS patient. What a physician can do is to note the oxygen administration in his or her medical documentation, thus demonstrating the complexity of the patient in the E/M service.

On occasion, your pulmonologist may have to resort to mechanical ventilation with positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) if the patient lapses into severe respiratory failure. For such ventilation management therapy necessitated by the patient’s condition, you can use the following codes depending on the length of the therapy:

• 94002 — Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day
• 94003 — ... subsequent days
• 94660 — Continuous positive airway pressure (CPAP) ventilation, initiation and management.

Note: In case of nursing facilities, you will report 94004 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; nursing facility, per day) instead of 94002 and 94003.

Because these ventilation management codes bundle E/M services, be sure not to report a follow-up visit E/M code (99231-99233, Subsequent hospital care …) when you report 94002, 94003 or 94660.