Pulmonology Coding Alert

Pulmonology practices should understand the implications of billing for services using E codes (E800-E999), which indicate an external cause of an illness or injury. The E codes give the Medicare carrier or other insurer information that either can expedite claim payment or lead the carrier to question whether there may be another primary payer. This can lead to late payment or a potential denial of the claim. Justifying Frequency of Services E codes can work in a pulmonologist's favor when they justify the frequency of visits to treat what otherwise may appear to be the same condition. For example, a 66-year-old Medicare patient presents with rhinorrhea (478.1), a cough (786.2) and low-grade fever (780.6). The pulmonologist performs an extended problem-focused exam with low-complexity decision-making. He diagnoses an acute upper respiratory infection (URI, 465.9) and prescribes a 10-day course of Augmentin because the patient is febrile, elderly and has had pneumonia. This visit is billed with 99213 (Office or other outpatient visit for the evaluation and management of an established patient).

Four days later, the patient returns to the pulmonologist's office complaining of epigastric pain (789.06). Suspecting an adverse reaction to the prescribed medication, the pulmonologist queries the patient about a history of gastric conditions, including peptic ulcer, which the patient denies.

To assess the origin of the pain, the pulmonologist performs a limited examination with straightforward decision-making (99212). The physician does not suspect that the symptoms are related to a gastrointestinal illness. Also, the patient informs the pulmonologist that she previously had stomach pain when taking amoxicillin. The pulmonologist concludes that the patient is having an adverse drug reaction and discontinues the antibiotic.

When coding the visit, use epigastric pain (789.06) as a primary diagnosis and E930.9 (Drugs, medicinal and biological substances causing adverse effects in therapeutic use, unspecified antibiotic) as a secondary diagnosis, along with the ongoing URI. "If you are billing two visits within such a short time frame, using the E code will distinguish the visits," says Mary Mulholland, RN, BSN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. "In this case, the E code relates to a payment issue having to do with frequency of services." Although E codes for adverse reactions to prescribed medications do not carry liability for the physician in most cases, they could if the pulmonologist did not supply information necessary for the patient to provide true informed consent. Physicians must explain (and document their efforts) the risks and benefits of taking certain medications that may cause potentially devastating side effects. Medicare as a Secondary Payer E codes also can specifically describe the etiology of a condition, such as a [...]