Pulmonology Coding Alert

Myth #1: You're limited to the precertified procedure and diagnosis

If you base your pulmonology diagnosis coding on myths and assumptions, you are just asking for denials and lost reimbursement. Instead, use our experts' proven strategies to debunk three common ICD-9 coding myths -- such as it's OK to fudge your fifth digits.
 
The following pulmonology coding scenarios will show you how to tighten up your diagnosis coding to guarantee quick reimbursement.

Myth #1: You're limited to the precertified procedure and diagnosis.

Your physician precertified a transbronchial lung biopsy (31628, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial lung biopsy[s], single lobe) based on one diagnosis.

But after the pulmonologist started the procedure, he discovered other problems requiring surgical attention. Because you precertified only the original diagnosis, you can't report the additional procedures, right? Wrong.

Strategy: You can precertify a procedure code range and submit the follow-up diagnoses after the fact, says Elisabeth P. Fulton, CPC, a coding and audit specialist in Winston-Salem, N.C.

Example: Suppose the radiologist preapproves thoracentesis (32000, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) for a patient with pleural effusion (511.9).

After the pulmonologist begins the procedure, he aspirates a small amount of blood and pus from the patient's lung, which means that the patient actually has hemothorax (511.8). The physician inserts a chest tube and performs thoracostomy to remove the fluid (32020, Tube thoracostomy with or without water seal [e.g., for abscess, hemothorax, empyema] [separate procedure]). Because the insurer only preauthorized the procedure based on the pleural effusion diagnosis, should the practice report both conditions?

Yes, but you can avoid this challenge if you pre-certify a code range rather than just one code, Fulton says.

"Before the surgery, tell the insurer's precertification department that the surgeon may perform other procedures if he discovers additional diagnoses," she says. "We tell the insurance company's precertification department that the surgeon may very well perform more than one procedure, depending on what he discovers when he gets in and looks around."

Lesson learned: Insurers rarely ask physicians to pre-certify just one CPT and diagnosis code. Occasionally, however, the payer might ask you to precertify the intended procedure based on the confirmed diagnosis. Therefore, you should precertify 32000 and make clear that your physician may perform and report more procedures if medically necessary.

Caution: If, after the surgery, the insurance company balks at paying for the thoracostomy (32020), the pulmonologist should write an appeal letter citing the date his practice requested preapproval, that the practice attempted to precertify a code range, and that he diagnosed hemothorax during the thoracentesis.

Myth #2: You should expect denials if you report signs and symptoms as primary diagnoses.

When your pulmonologist confirms a diagnosis, you have to use that ICD-9 code, according to CMS' 2002 program memorandum AB-01-144.

But when your physician doesn't specify a particular diagnosis, you should report the patient's signs and symptoms, coding experts say.

What to do: Suppose a patient's primary-care physician requests that your pulmonologist examine the patient for suspected sarcoidosis (135).

Your pulmonologist documents "Rule out sarcoidosis" in the medical chart. ICD-9 coding guidelines state that you should not report "rule out" diagnoses.

But you can still assign other symptoms, such as fatigue (780.79), cough (786.2) and shortness of breath (786.05) if documented, to describe the patient's symptoms in the absence of a sarcoidosis diagnosis.

And, when the pulmonologist concludes that a patient does not have the diagnosis the physician once suspected, you can report only documented symptoms and secondary codes, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.

Myth #3: Fudging that fifth digit is OK.

Coders have a right to worry about using ICD-9 codes that are missing that crucial fifth digit: To medically justify a procedure, the pulmonologist must supply the most specific ICD-9 code that describes the patient's condition, which means including the fifth digit.

For example, you will forfeit deserved reimbursement if you bill for extrinsic asthma treatments using the 493.0 ICD-9 code. To appropriately report extrinsic asthma, you must apply the right fifth digit, such as 493.01 (... with status asthmaticus).

Protect yourself: If your physician selects an incomplete diagnosis code or if the documentation does not include the diagnosis that your physician has selected, you should alert your physician to the coding discrepancy. This way, you can educate your physician on selecting the most accurate codes in the future.

The bottom line: Ignoring these issues can lead to delays in payment and/or an increased liability for inaccurate information.