Pulmonology Coding Alert

Safety net: You may want to adopt an all-payer modifier 59 policy
 
The Office of Inspector General's increased scrutiny of claims with modifiers 25 and 59 has many coders worried about their pulse oximetry claims.
 
When a third-party payer bundles 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination) into 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), you may wonder if using modifier 59 (Distinct procedural service) instead of modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the  procedure or other service) in these instances is appropriate.
 
The ugly truth: The insurer has probably followed Medicare's lead and considers 94760 a bundled service. "Almost none of the managed-care organizations (MCOs) pay for the pulse oxygen," says Richard Lander, MD, a national coding speaker and coding consultant in Livingston, N.J. Check out the following scenario to see if your pulse oximetry coding is up to speed.

Double-Check ICD-9 Codes

Consider the following claim submitted by a fellow coder. After you review the services and procedures, take a stab at how you would code the claim before you check out our expert advice below. Decide whether you should use modifier 59 on 94640 for an encounter that involves:

 • 99215     ICD-9: 493.00, 493.90
 • 94760
 • 94640
 • J7613
 • A7003
 • 94060.

Hint: Each modifier indicates these encounter circumstances:
 
• 25 -- identifies the E/M service as significant and separately identifiable from a same-day procedure or service performed by the same pulmonologist
 
• 59 -- indicates that the pulmonologist rendered "either a procedure or service that was different or independent from other things he did that day," Lander says.
 
Step-by-step solution: Before you zoom in on the modifier as the potential key to unlocking payment for 94760, review your diagnoses.
 
A fifth-digit subclassification of 2 -- 493.02 (Extrinsic asthma; with [acute] exacerbation) or 493.92 (Asthma, unspecified; with [acute] exacerbation) -- better shows the medical necessity for performing spirometry with bronchodilation (94060, Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) and nebulizer treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes ...) than the unspecified 0 digit, says Catherine A. Hudson, RMA, RPT, in Marietta, Ga.
 
On claims involving this level of service (99215), the patient "is almost always exacerbated," she says.
 
In fact, you should use only the definitive diagnosis, such as 493.02, not the preliminary diagnosis (i.e., 493.92).

Let NCCI Be Your Guide

Next, refer to the National Correct Coding Initiative (NCCI). The edits designate the pulse oximetry bundles with a 0, says Vicky V. O'Neil CPC, CCS-P, coding and compliance educator in St. Louis, Mo. That means you can never override the inclusion -- even with modifier 59.
 
Reality: This policy matters when dealing with a third-party payer. "Most private payers' software edit programs are built from the ground-up based on the national edits with some additions," O'Neil says.
 
Best practice: O'Neil encourages coders to code based on NCCI for all payers. "Adopting an all-payer policy in which you code uniformly will give you a solid foundation to support your appeals," she says.  

Signal Separate Site With 59

Modifier 59 does come into play in another pulmonology scenario. If a pulmonologist performs a bronchoscopy with bronchial biopsy (31625, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial or endobronchial biopsy[s], single or multiple sites) and later the same day performs a second bronchoscopy on the patient because of hemoptysis (31622, ... diagnostic, with or without cell washing [separate procedure]), you will have to use modifier 59 to indicate that the second bronchoscopy was a distinct procedure from the first bronchoscopy with bronchial biopsy.
 
Because the second bronchoscopy is a separate procedure that occurs at a different time of the day, modifier 59 is appropriate.
 
Suppose your pulmonologist is following an outpatient with obstructive bronchitis (491.20) who has increasing shortness of breath (786.05). The doctor discovers a new pleural effusion (511.9) and performs a thoracentesis on the same visit.
 
You should code the office visit (99212-99215, Office or other outpatient visit for the E/M of an established patient) with modifier 25, plus the thoracentesis: 32000, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent, or 32002, Thoracentesis with insertion of tube with or without water seal (e.g., for pneumothorax) (separate procedure), depending on whether the physician placed a plastic catheter in the pleural space to drain the effusion.