Pulmonology Coding Alert

Coding for the pulmonary monitoring of cystic fibrosis (CF) patients involves reporting both E/M services and testing, which involves working your way through bundling issues and distinguishing between those services provided in the office and those performed outside.

Pulmonologists, frequently called on to monitor the pulmonary manifestations of CF, perform services such as spirometry, chest x-rays and sputum testing to determine the CF patients condition throughout the course of the disease. In addition, they provide counseling and coordination of care to address any pulmonary problems caused by the condition.

CF is an inherited disease that causes the mucus lining the surfaces of internal organs to become thick, dry and sticky. This denser mucus in the lungs gives bacteria a uniquely favorable place to grow. Also, CF patients are susceptible to more strains of bacteria than other people and have difficulty fighting these infections.

The pulmonologists goal when treating CF is to slow lung damage, improve breathing by loosening and thinning mucus, and prevent or reduce lung infections. "To this end, the physician employs five main treatment methods to help maintain CF patients lung health," says Vickie ONeil, CCS-P, a reimbursement specialist with Illinois Heart & Lung Associates in Bloomington, Ill.

1. antibiotics to help control and prevent lung infections
2. bronchodilators to help open airway diameters in the bronchial tree
3. mucolytics to help thin mucus
4. airway clearance techniques, such as chest physical therapy (94667, Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation; 94668, subsequent), exercise and the Flutter device, to remove mucus from the lungs
5. bronchial alveolar lavage (31624, Bronchoscopy [rigid or flexible]; with bronchial alveolar lavage) to help clear away excess mucus.

A potential sixth treatment option for progressed pulmonary disease in CF patients is a lung transplant. (For more on coding the pulmonologists role in lung transplants, see the July and August 2002 issues of Pulmonology Coding Alert.)

Pulmonary physicians often use spirometry (94010-94070) to monitor the lung function of their CF patients. You should use 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) to indicate repeat spirometries performed to evaluate a patients response to newly established treatments, to monitor the course of CF or to evaluate a patient continuing with symptoms after initiating treatment. If the pulmonologist performs the spirometry both before and after administering bronchodilators, you should report 94060 (Bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]), which includes all of the work of 94010 but gives a better analysis of the problem and the effects of treatment.

There are a variety of additional codes, but many are considered bundled into 94060 by the Correct Coding Initiative (CCI) including 94200 (Maximum breathing capacity, maximal voluntary ventilation), 94375 (Respiratory flow volume loop), 94640 (Nonpressurized inhalation treatment for acute airway obstruction), 94650 (Intermittent positive pressure breathing [IPPB] treatment, air or oxygen, with or without nebulized medication; initial demonstration and/or evaluation), and 94770 (Carbon dioxide, expired gas determination by infrared analyzer). These component codes cannot be reported on the same date in addition to 94060.

On the other hand, 94200, 94640 and 94770 have a superscript of "1" in the Correct Coding Initiative, says Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the department of medicine at the University of Pennsylvania in Philadelphia. Therefore, they could be reported separately if performed as a separate and distinct procedure and not part of the same testing. To show this, you should append them with modifier -59 (Distinct procedural service), Pohlig says.

"There are other pulmonary function tests, however, the pulmonologist may use to monitor the CF patients condition that are not bundled into 94060," ONeil says. These tests include 94350 (Determination of maldistribution of inspired gas: multiple breath nitrogen washout curve including alveolar nitrogen or helium equilibration time) and 94720 (Carbon monoxide diffusing capacity [e.g., single breath, steady state]). These function tests can be billed separately with 94060 without appending a modifier, ONeil says.

The chest x-ray is another important tool for pulmonologists monitoring the CF patients condition because it allows the physician to detect subtle changes in the lungs. But how to code the service depends on where the x-ray is taken.

If the pulmonary physician owns the x-ray equipment, he or she can bill for the x-ray (71010-71035). Frequently, however, the doctor sends the patient to an outside facility, which takes the x-rays and sends the films and a report back to the pulmonologist. In this case, the pulmonologist should factor his or her review of the x-ray(s) into the medical decision-making portion of the E/M service (99201-99215) provided to the patient.

If the pulmonologist sends the patient to an outside facility but interprets the x-ray(s) and generates the report, he or she should bill the appropriate x-ray code appended with modifier -26 (Professional component). "In this instance, the pulmonologist would have to be the only one interpreting the films," Pohlig says. The pulmonary physician could not do this in addition to the radiologists interpretation and charge for the service. "Be aware that some insurers contract to pay only radiologists for this service," Pohlig adds. "Keep this in mind when negotiating a new contract. Make a list of all the services provided by your pulmonologist and have them included as payable services in the contract."

The pulmonologist may also obtain sputum for smears and culture, to be performed by a regional microbiology commercial lab, to monitor the CF patients condition. To acquire the sputum sample, the physician may use an aerosol inhalation to induce sputum (94664, Aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation). Any subsequent procedures (on different days of service) to obtain sputum should be coded 94665 (... subsequent). If the doctor does not use the aerosol treatment to induce sputum production, then there is no additional payment for obtaining the specimen.

CMS recently announced that it will institute several new ICD-9 codes for CF in 2003. Now, only two diagnosis codes for CF exist: 277.00 (Cystic fibrosis; without mention of meconium ileus) and 277.01 ( with meconium ileus).

For 2003, the agency will add 277.02 (Cystic fibrosis with pulmonary manifestations), as well as two other CF codes denoting manifestations in other body systems and one indicating a CF gene carrier. Beginning in January 2003, you should link any CF treatment, monitoring or other services to 277.02 on the CMS 1500 form when submitting claims.