Pulmonology Coding Alert

Many patients with chronic respiratory conditions rely on their pulmonologist to provide preventive care services, ranging from annual wellness exams and preventive health counseling to screening tests, such as electrocardiograms (ECGs). While Medicare doesn't cover most preventive care, often a patient will have a problem-oriented visit and a preventive or wellness service on the same day. "Or, some patients with asthma (493.20), for example, may ask the pulmonologist to perform an ECG simply to check them out even though they have no history or symptoms of heart disease," says Theresa Thompson, BS, CPC, a coding specialist in Sequim, Wash.
Coding the Combination Visit
The following scenarios illustrate how to code a visit that combines preventive services and an evaluation of an existing illness or a problem discovered as part of the history and physical.
 
Example #1: A patient with chronic emphysema (492.x) presents for an annual physical. The patient tells the physician he feels good and is participating in a smoking-cessation program that has relieved his shortness of breath. While the purpose of the visit is a wellness exam, follow-up pulmonary function testing is performed to validate the improvement in lung function. The nurse obtains and performs a urinalysis (81000) and an ECG (93000-93010), and the physician performs a review of all organ systems. The pulmonologist also provides preventive health counseling about sexually transmitted diseases, weight maintenance, seat-belt safety, etc.
 
"Since Medicare only covers pulmonary services that are problem-oriented," says Carol Pohlig, BSN, RN, CPC, a reimbursement analyst for the Hospital at the University of Pennsylvania in Philadelphia, "in the above example the pulmonologist bills, and expects payment for, the problem-oriented evaluation of the patient's emphysema." In this case, bill 99213 (Established patient office visit level three) and 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation).
 
In addition, correct coding practices require appending modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99213.
 
If an x-ray and ECG were obtained to assess the progression of the emphysema, which in this case they were not, these tests would also be problem-oriented, and payable by Medicare if medically necessary.
 
Noncovered services, in this case, would include the screening urinalysis, V81.6 (Special screening for other and unspecified genitourinary conditions) or V81.5 (Special screening for asymptomatic bacteriuria), which was performed in the absence of symptoms or illness, and the preventive exam and counseling (99397, Preventive service for an established patient age 65 or older). The urinalysis and preventive medicine services are reported with modifier -GY (Item or service statutorily excluded or does not meet the definition of [...]