Pulmonology Coding Alert

The patient breathes into a mouthpiece of a tube connected to the spirometer, which measures the airflow. The procedure is useful to detect obstructive airway diseases, such as asthma and chronic obstructive pulmonary disease (COPD).

Reimbursement for spirometry is now based on CPT codes, not on the diagnosis. But the payment depends on whether you establish a credible medical necessity for the procedure by applying the correct diagnosis code. These codes tell the payer why the pulmonologist performed the spirometry. And increasingly, carriers are denying payment if the ICD-9 codes are not specific enough.

Ideally, diagnosis information should come from the pulmonologist's clear, concise and specific diagnosis written in the patient's chart. But this kind of detail is often the exception in many practices. "You may want to use an encounter form that lists the common diagnoses along with a clear indicator when more specificity is needed," says Heidi Stout, CPC, CCS-P, coding and reimbursement manager for University Orthopaedic Associates in New Brunswick, N.J. This will help educate the pulmonologist about which ICD-9 codes require more information. For example, you can use a line after the code to clearly indicate that more digits are required (i.e., 491.__), Stout says.

2. Use the code with the highest specificity. No matter how well the pulmonologist communicates the patient data, you must ensure that you use the right code and that it is being carried to the highest digit possible. This involves not only noting any caution or warning symbols in the ICD-9 manual (some color-coded books use yellow for nonspecific codes and red for those with missing digits) but also having a good working knowledge of the terminology associated with spirometry. From the example above, if the physician sees a patient for chronic bronchitis, you will have to support the diagnosis codes by gathering enough information to know that the patient has obstructive chronic bronchitis with COPD.

In this example, the specific code to report is 491.21 (Obstructive chronic bronchitis with acute exacerbation). The fourth digit indicates that there is an element of COPD present, and the fifth digit clarifies that there is an acute exacerbation of the chronic condition. Although carrying out to the fifth digit is mandatory, you occasionally have to use an unspecific code if no ICD-9 code exists that matches the pulmonologists' documentation.

3. Run frequent reports. You can see the real evidence of good diagnosis coding by evaluating regular code reports. About every two months, use your billing software to generate a report of the top 50 diagnosis codes and top 50 CPT codes each physician used. Carefully review the reports, noting which nonspecific codes the pulmonologists used and how often. Report this information to the physicians and keep track of each report to benchmark progress and trends.

In addition, updating your encounter forms at least annually is always beneficial for your practice, says Lisa M. Clifford, CPC, owner of the multispecialty coding firm Clifford Medical Billing Specialists Inc. in Naples, Fla. This should eliminate the potential for using outdated or deleted codes. Your physicians will also be able to choose diagnoses that reflect their current patient population. Pulmonary physicians are frequently unaware of the many ICD-9 codes available to them. They only see the small sample presented to them on their billing slip, and many limit their selection to these codes.

"You should be sure to include all applicable diagnosis codes on the encounter form to give the doctor the full range of options," Clifford says. "If you only include those codes your carriers have indicated show medical necessity, you could be accused of coding for payment, which can be deemed fraudulent."