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Pulmonology Coding Alert

Use E Codes to Clarify Claims

Published on Wed May 01, 2002

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 pneumothorax from a car accident, sharp injury or fall. "Use of an E code simply means there was an accident or fall, as examples, but it doesn't necessarily mean someone else is liable for the bill," says Michelle Logsdon, CPC, CCSP, coding manager at Cash Flow Solutions Inc. in Lakewood, N.J.

"Yet if you use an E code, it puts up a flag for Medicare, which will send a third-party liability letter to the insured asking him or her if someone else is liable for the bill," Logsdon adds. So, if you do identify a primary payer other than Medicare, make sure to indicate that information on the CMS 1500 form. Such primary payers could include the following:

  • Workers' compensation insurance for a work-related lung condition

  • Black lung benefits (federal health coverage for lung conditions caused by coal mining, construction of coal mines or transport of coal)

  • An automobile or other liability insurer such as a homeowner's policy

  • A lawsuit alleging liability of another party for an injury or illness.

    The claim may be held up while the carrier investigates whether another payer is responsible for reimbursement, as indicated by an E code or ICD-9 codes commonly associated with work-related illnesses, such as 506.x (Respiratory conditions due to chemical fumes and vapors). In this case, use an E code to identify the condition's cause.

    Logsdon advises you to ask patients during registration to provide and sign a brief description of how an injury or condition occurred and whether they believe someone else is liable. "The pulmonologist is dependent on the patient providing the information requested by the carrier to get paid," Logsdon notes. "But if you have something on file, at least you can provide the information to the carrier. In some cases, carriers will accept that if they aren't getting the information from the patient."

    Occasionally, payment from a non-Medicare primary payer is substantially delayed, for example, because of a contested black lung or workers' compensation claim or protracted lawsuit. "Medicare can be billed conditionally for nonpayment after 120 days of the first bill sent or denial notification only for no fault, including automobile or other insurance, workers' compensation, black lung benefits or any liability insurance," says Jacqueline D. Moses, manager of FR&R Healthcare Consulting Inc. in Deerfield, Ill.

    Black Lung Benefits

    Carriers will have a list of diagnoses commonly associated with black lung disease to check against Medicare claims (see list of codes below). Pulmonology practices should be aware that if the common working file (CWF) lists the beneficiary as having black lung benefits available, any claim submitted for that beneficiary with Medicare as the primary payer may be subject to an automated review.

    If the claim services fall within the effective/termination dates of the black lung coverage, all ICD-9 codes on the claim will be compared to the list of those related to black lung. If such a code is recorded on the claim, the carrier will send the claim back to the pulmonologist for possible "Medicare secondary payer cost avoid development." In other words, Medicare may refuse to pay the claim until the primary insurer denies it.

    Pulmonologists, therefore, should be aware of whether the patient may have black lung benefits or another payer on record with the CWF. The pulmonologist's billing office may have to correct the CWF by contacting the carrier if the beneficiary does not really have black lung benefits or risk having their claims denied repeatedly.

    If the pulmonologist treats the beneficiary for a diagnosis that could be interpreted as associated with black lung but the pulmonologist determines that it is not related, the pulmonology office billing staff should inform the carrier.

    Coding Iatrogenic Problems

    E codes can also be used to identify iatrogenic complications, such as postoperative infections. For example, 997.3 is used to report respiratory complications resulting from a procedure.

    An E code might be used if the pulmonologist clearly identified that a patient's postbronchoscopy Pseudomonas infection was associated with a nonsterile or faulty bronchoscope. Researchers at Johns Hopkins recently informed the U.S. Centers for Disease Control and Prevention in Atlanta that they have associated such infections with bronchoscopes that have loose ports, which may act as a reservoir for Pseudomonas. (For more information, call Olympus at 800-848-9024 or the U.S. Food and Drug Administration at 800-638-2041.)

    Yet coding experts issue strong caveats about using an E code when the pulmonologist is not sure of a condition's etiology, even if he or she strongly suspects that the problem is iatrogenic. "The physician cannot code a 'rule out' even if he or she has a high degree of suspicion" regarding the cause of infection following a bronchoscopy, cautions Mulholland. "Unless you had a positive culture from the bronchoscope to prove that it was the cause of the patient's infection," do not to use the E code, because it denotes some measure of liability.

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