Pulmonology Coding Alert

Question: Which codes should I use for medications the pulmonologist ordered for the treatment of emphysema?

Maryland Subscriber

Answer: Medications are coded using HCPCS codes, e.g., J codes. The physician has to purchase the drug from a pharmacy or pharmaceutical company to report and expect payment from an insurer. A physician should not expect to be paid for a drug that he or she has not purchased. Therefore, any drug ordered by the physician for the patient to purchase cannot be reported to the patient's insurer. The pharmacy or patient would report these medications to the insurer. The drug should be provided to the patient in an outpatient setting, such as the physician's office. The physician should not report any drug provided to an inpatient. This is a hospital expense for which the facility should bill. The drug should be FDA-approved and not of a form that can be self-administered. It must require administration by the physician or by his or her staff under the physician's supervision.

The pulmonologist's notes should document the medication route and quantity so you can assign the proper code(s). For example, the patient presents with shortness of breath and wheezing. The physician determines that the patient has bronchospasms and administers an inhalation treatment. The patient receives 2 mg of albuterol through a nebulizer. The physician reports J7618 or J7619, depending on whether the drug is supplied in concentrated form or unit dose. Because either code represents only 1 mg, report two "units" of the appropriate code in box 24-G of the CMS-1500 form.

The following are codes for potential medications pulmonologists may use to treat emphysema: