Pulmonology Coding Alert

Effective communication is essential between health care providers and their patients. A patient who is hearing-impaired may present a challenge to effective communication. The Americans with Disabilities Act (ADA) requires that physicians provide a sign-language interpreter for complex office visits if a patient requests one. And, there are ethical ways to recover the cost of using an interpreter.

According to the guidelines of the Registry of Interpreters for the Deaf (RID), a national membership organization for interpreters and transliterators, An interpreter should be present in all situations in which the information to be exchanged requires effective communication, such as taking a medical history, explaining tests, procedures and diagnoses, planning treatment, providing discharge instructions and scheduling follow-up care.

Who Pays for Interpreter Services?

Melanie Witt, RN, CPC, former program manager with the Department of Coding and Nomenclature, American College of Obstetricians and Gynecologists, says that in most instances the services of an interpreter during a patient encounter become part of your overhead cost.

You cannot bill an evaluation and management (E/M) service for the services of an interpreter. Witt says billing for an interpreters services using ICD9 Code V40.1 (problems with communication) is a common error. If
you bill for an interpreters services using V40.1, you imply that you are billing for a communication problem with the interpreter.

The best approach, Witt advises, is to establish everything up front with your carrier before the patient ever visits the office. Dont wait until after the fact. Arrange before the visit how to bill it, and you can
avoid a lot of problems. You should call your carrier before the patients visit to your office and ask for the carriers reimbursement policy and procedure on interpreter services.

Some companies that provide managed-care services have an interpreter available; some carriers actually have an interpreter on staff who will meet with the hearing-impaired patient and the physician; and some carriers establish a direct payment with an interpreter. In many instances, preferred physician options and indemnities leave it up to the provider to determine how to proceed with obtaining interpreter services. In any case, if a deaf patient requests this [auxiliary] service, it must be provided.

Billing Options

If the patient encounter is long, Witt suggests another approach is to use prolonged visit codes. At a 99215-level visit (office or other outpatient visit for the evaluation and management of an established patient which requires at least two of three key components) instead of the usual time it took for you to conduct the patient history, the complaint and verification, you must add the additional time it took to work through a sign-language interpreter. You may bill for prolonged physician services for direct face-to-face because you used an interpreter and added to the complexity of the visit by doing so, says Witt.

Its not an E/M service, Witt continues. But if its a true level-four visit, 99214, ()office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of three key components)) you should bill it with add-on code 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service) because youve exceeded the typical time for the office visit
by 30 minutes.

Carol Pohlig, RN, CPC, is a reimbursement analyst for the Office of Clinical Documentation, Department of Medicine at the University of Pennsylvania in Philadelphia. Her office documents physician-reimbursement procedures. Pohlig concurs with Witt, and says that if at least 50 percent of the total physician visit timespent face-to-face with the patientinvolves counseling or coordinating care, the total visit time can be used to select the appropriate established patient E/M visit level.

Says Pohlig, The established office visit can also be billed based on the extent of the component documentation (history, exam or medical decision-making) in addition to an outpatient prolonged-care code if the physician spent at least 30 minutes of face-to-face time with the patient discussing the issues [with an interpreters help].

For example, a detailed level of E/M service for a patient with an acute exacerbation of asthma might take 10 minutes, Pohlig continues, and there was an additional 30 minutes spent discussing the treatment issues noted above. Then, you can code a 99214 and 99354. Pohlig adds that the ICD-9 codes to use are wheezing (786.07), shortness of breath (786.05) and asthma (493.90). If there is adequate documentation in the chart to show that the persons disability required an interpreter for communication and to help the patient understand the physicians assessment and plan, this should justify the complexity of the visit and the level billed, in case of an audit.

Pohlig says not to append modifier -22 (unusual procedural services) to the visit because this approach can prevent timely reimbursement. Often, she says, modifier
-22 will result in a denial based on a need for more information. Then, documentation would have to be sent to the carrier.

Another approach to obtaining reimbursement for interpreter services is to determine if any federal or state government-sponsored healthcare programs apply to your practice. For example, an agreement exists between the District of Columbias Department of Health and the Office for Civil Rights (OCR) of the Department of Health and Human Services to ensure that low-income persons with hearing impairments have access to critical health services and programs, such as Medicaid-funded physicians visits. The D.C. Department of Health agreed to contract with a local sign-language interpreter program to provide interpreter services in the offices of primary care physicians. Then the department established procedures for physicians who participate in the Medicaid program to receive payment when treating hearing-impaired patients. All costs for the interpreter service are being absorbed by the D.C. Department of Health.

)Editors note: A booklet, ADA Questions and Answers for Health Care Providers, is available from the National Academy, Gallaudet University, 800 Florida Avenue. NE, Washington, DC 20002-3695.)