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Pulmonology Coding Alert

Sick and Well:

How to Code the Combination Visit

Published on Mon Apr 01, 2002

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 any Medicare benefit).
 
The diagnosis for the general medical exam is V70.0 (General medical examination).
 
Example #2: Another common scenario is a combination well and sick visit that occurs when a patient presents for a wellness exam and feels fine. However, during the review of systems, the patient complains of a sign or symptom. The patient may say, "Now that you mention it, I have been having some pain when I breathe deeply." The physician listens to the patient's chest and hears diminished breath sounds on the right side. "This definitely describes the 'textbook' scenario for billing preventive medicine and an E/M service during the same visit," Pohlig says.
 
In this case, the physician performs a significant work-up to address the pain, including a chest x-ray and white blood cell count, and gives a diagnosis of pleurisy (511.0, without mention of effusion or current tuberculosis). Code 99213 is billed for the E/M service.
 
"Link the sick diagnosis (511.0) to 99213 and append modifier -25," says Mary I. Falbo, MBA, CPC, president of Millenium Healthcare Consulting, Lansdale, Penn.,  because it is being reported on the same day as another service (preventive medicine in this case). Or, if the pulmonologist is unable to make a diagnosis on that day, code the symptom of painful respiration (786.52) with modifier -25.
 
"Bill the noncovered wellness services using modifier -GY for statutorily excluded services," Falbo adds. In this case, bill the wellness exam (99397) with a diagnosis for a general medical exam (V70.0) and append modifier -GY to 99397.

Billing the Unexpected Finding

A screening may uncover an unexpected or incidental finding. While the first inclination is to code what was intended to be a screening as a diagnostic test, this is not allowed under Medicare rules. For example, a 68-year-old Medicare patient presents for a wellness exam and has no complaints. The patient was treated in the past for a recurrent pneumonia, which resolved a year ago. A chest x-ray is performed as a preventive screening and shows a mass.
 
How the x-ray is billed varies, Pohlig says. "According to CMS rules on diagnostic testing and screening, the physician must code the reason for the services as the primary diagnosis." If the reason for the x-ray is screening, V81.4 (Screening for other and unspecified respiratory conditions) is listed first with the lung mass code (786.6) listed second. Code the physical exam as 99397 with a diagnosis for a general medical exam (V70.0) and append modifier -GY to 99397.
 
If the x-ray is performed to ensure that therapy is working on a pneumonia patient, the test is diagnostic and should be coded as 486 (Pneumonia, organism unspecified).
 
Note: For pneumonia diagnoses, you cannot use a more specific code unless you have proof (via pathology and/or laboratory findings) of the specific organism causing the pneumonia.

Coding the Noncovered ECG

While preventive services and wellness exams are statutorily excluded from Medicare, a patient may request a service that the physician believes Medicare won't cover because the service does not meet the Medicare-designated medical-necessity requirements or utilization parameters. For example, an otherwise well asthma patient might benefit from an annual ECG. In this case, a diagnosis of asthma (493.20) most likely would not justify the medical necessity of an ECG since the patient has no history or signs and symptoms of cardiovascular disease.
 
In this case, use asthma as the primary diagnosis and expect a denial for medical necessity. "Most likely, the carrier will deny the claim because Medicare will look for cardiovascular-specific problems" to justify payment for the ECG, Pohlig says. Bill the service with 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) since the practice owns the ECG equipment and interprets the test. If the practice does not own the equipment, only bill for the interpretation and report (93010).

Secure Payment

To get paid for performing the ECG for surveillance, obtain a signed advance beneficiary notice (ABN) indicating that the patient understands that he or she may be responsible for payment of the services if Medicare denies the claim as "not reasonable and necessary." While Medicare beneficiaries are responsible for paying for statutorily excluded services (e.g., wellness exams), many secondary insurers, such as Medigap plans, will pay for these preventive health services. However, you must first obtain a denial from Medicare to bill the secondary insurer.   

Modifiers -GZ (Item or service expected to be denied as not reasonable and necessary) and -GA (Waiver of liability statement on file) are used to bill an item or service that is normally covered by Medicare but that the physician believes won't be a reasonable and necessary service. In the case of the ECG (93000), bill Medicare by appending modifier -GA to 93000 if an ABN has been obtained prior to providing the service.
 
If the patient refuses to sign the ABN and demands the service, service can be declined, but this may subject the physician to liability. As an alternative, ask your carrier for specific instructions for annotating the ABN and billing a service if the beneficiary refuses to sign the form.
 
Physicians are not required to obtain an ABN for services that are not part of the Medicare benefit, such as wellness exams. However, most practices tell beneficiaries that Medicare won't pay for a statutorily excluded service prior to providing it. According to Pohlig, ABNs are often used as the "documentation" that the information was discussed. "Although not required for noncovered services, they provide the proof that the conversation (between the physician and the patient) took place," she says.
 
"According to the 1997 Balanced Budget Act, the patient must pay the difference between the sick visit and the total billed visits, which includes the wellness exam," says Falbo.

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