Pulmonology Coding Alert

Question: One of our doctors performed a Swan-Ganz catheter procedure, but complications ensued, and we needed a radiologist present. We also needed to perform a fluoroscopy. The whole procedure took two and a half hours. Later in the day, the patient needed critical care. Can I use a prolonged service code in this case?

Idaho Subscriber

Answer: When performing such services as critical care and prolonged services along with separately billable procedures, you must understand that the time spent performing the procedure isnt billable as part of the time of critical care or prolonged services:

99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour)

99357 (... each additional 30 minutes)

If the documentation clearly described the complicated procedure, you might consider submitting the 93503 (insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes) with a -22 modifier (unusual procedural services).

If the physician performed a separately identifiable evaluation and management (E/M) in the morning at the time of the Swan-Ganz, that service is billable. In the afternoon, when he or she provided the critical care, you may also bill from the critical care codes, but you should append a modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the critical care code. Be prepared to submit documentation to demonstrate that the critical care was performed at a later time of day from the original E/M service if both were billed. Also be prepared to submit documentation to demonstrate the difficult circumstances of the Swan-Ganz insertion if billing with a -22 modifier.