Pulmonology Coding Alert

Overlooking symptoms could cost you major dollars.

Histoplasmosis (B39.-) is caused by breathing in spores from a fungus found in bat or bird droppings. A person gets infected when he or she inhales this fungus into the lungs when the fungus is airborne. Although lungs are most common site of infection, other organs also sometimes get infected.

ICD-9: Right now, you should report this with 115.xx (Histoplasmosis). Your fourth digit will specify the type of histoplasmosis, and the fifth digit with specify the manifestation:

Fourth digit:

• 0 = histoplasmacapsulatum
• 1 = histoplasmaduboisii
• 9 = histoplasmosis unspecified

Fifth digit:

• 0 = without mention of manifestation
• 1 = meningitis
• 2 = retinitis
• 3 = pericarditis
• 4 = endocarditis
• 5 = pneumonia
• 9 = other.

ICD-10: When your diagnosis system changes, you’ll look at B39.- (Histoplasmosis) instead. Your full cache of possibilities are as follows:

• B39.0—Acute pulmonary histoplasmosiscapsulati
• B39.1—Chronic pulmonary histoplasmosiscapsulati
• B39.2—Pulmonary histoplasmosiscapsulati, unspecified
• B39.3—Disseminated histoplasmosis, capsulati
• B39.4—Histoplasmosiscapsulati, unspecified
• B39.5—Histoplasmosisduboisii
• B39.9—Histoplasmosis, unspecified.

Note: Make sure that your physician’s generalized histoplasmosis documentation does not include hypersensitivity pneumonitis due to organic dust (J67.-) or mycosis fungoides (C84.0-) as they are excluded from B39.-.

The following case will illuminate the intricacies of coding histoplasmosis and its treatment:

A 68-year-old patient presents to the pulmonologist for evaluation of chronic dry cough, muscle pain and chills. During the visit, the pulmonologist goes through the patient’s lengthy medical records and the most recent chest x-ray and finds normal results. The physician performs an extensive history and physical. The patient discloses his daily exposure to animal manure due to his maintaining a modest bird farm. The physician conducts a skin test suspecting histoplasmosis and also prescribes a complete blood test after the consult. A follow-up visit in two days is advised to interpret the test results and perform a more extensive diagnostic workup. How will you report this?

Keep Your Eyes Peeled for Symptoms

There are varying symptoms of histoplasmosis. It could come on like a mild cold or flu-like respiratory illness. However, most of the patients complain of a mix of the following:

• feeling generally ill
• fever (R50.9)
• nonproductive cough or dry cough (R05)
• headache(R51)
• chest pain (R07.9)
• chills (R68.83, Chills [without fever])
• hoarseness (R49.0)

Caution: The bill will be generated by the pathology lab, not the pulmonologist. The physician will only verify in writing that the lab’s report has been personally checked. The physician will also report the appropriate diagnosis coding with the lab order (either the reason for the test or the visit) so that the pathology lab analyzing the specimen can get paid. In this case, the ICD-10 codes confirming the medical necessity of the lab test are chronic dry cough (R05) and chills (R68.83).

Go for Screening Test to Confirm Suspicions

You have a range of E/M codes, such as those for consultation (99241-99245) for payers who still accept these codes. In this particular case, your best choice maybe 99244 (Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderatecomplexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient’s and/or family’s needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family), as the pulmonologist confirmed the required three components of comprehensive history and exam, review of lengthy medical-record documentation, and the need for further testing to confirm theconsidered diagnoses.

Under current rules you can expect to get about $185.92 for reporting 99244 (5.19 RVUs multiplied by the 2014 conversion factor of 35.8228). However, you cannot report a consultation code if the payer is affiliated withMedicare. You must report a new (99201-99205) or established (99212-99215) visit, depending on whether the patient has been seen by anyone in the group within the last three years in any setting (inpatient or outpatient).

Additionally, you will also report 86510 (Skin test; histoplasmosis) for the patient’s confirmation histoplasmosis skin test but only if performed by the physician, and not a lab. This could fetch you a payment of up to $6.45 (0.18 RVUs multiplied by the 2014 conversion factor of 35.8228). Combining the two services for this consult, you can safely bank on $192.37.

Skin test basics: The skin test can be of two types – percutaneous and intradermal. The service provider cleans an area of the patient’s skin, usually the forearm. 

Percutaneous test – here, the technician places a drop of solution containing a possible allergen (a drug or biological substance) on the skin. A needle is used to perform a series of scratches or pricks which allows the solution to enter the skin. If the skin develops a red, raised itchy area, it indicates that the person is allergic to that allergen.

Intracutaneous or intradermal test – When a substance does not cause a reaction in the skin prick test but is still suspected as an allergen for that person, then intradermal test is done. A small amount of the allergen solution is injected into the skin’s deeper layers which produces allergic response if the person is allergic to that allergen.

The provider checks the injection site at 24 hours and at 48 hours for signs of a reaction. Occasionally, the reaction may not appear until the fourth day.

Unless histoplasmosis is confirmed, report the corresponding signs/ symptoms for any testing.

The Follow-Up Service Decides Future Coding

Continuing with this case, the pulmonologist reads the results of the skin and blood tests to the patient in his follow-up visit and confirms that the patient has acute pulmonary histoplasmosis. He conducts a 30 minutes counseling session with the patient, discussing the test results and advising him on the ill effects of continued exposure to bird droppings. The doctor concludes that due to the patient’s less morbid symptoms, no other treatment than an antifungal drug is required. She counsels the patient to avoid the proximity of the bird farm for risk reduction.

Code it: Again,you have a choice of any established patient visit code among 99211-99215. The most appropriate in this case would be 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient’s and/or family’s needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family). Then, you should add B39.0 (Acute pulmonary histoplasmosiscapsulati) with 99214 to report the final diagnosis.

Desist: Do not bill 86510 again for the patient’s return visit for the test results interpretation. You should also avoid billing another office visit if the histoplasmosis skin test reading is the only service provided. Although you may be able to get reimbursement for a minimal E/M (e.g., 99211) for the reading from some payers, it also involves a co-pay for the patient for this service.