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Pulmonology Coding Alert

Use Proper Diagnoses,Test Coding to Stop Losing Payment for Post-Transplant Care

Published on Thu Aug 01, 2002

When you are coding post-lung transplant care, be sure you report the correct diagnosis codes as well as the appropriate tests performed to ensure you receive full reimbursement for your services.

Frequent patient follow-up visits by the lung transplant team, including the pulmonologist and transplant surgeon, are crucial during the first few months following a lung transplant. In addition to monitoring the functions of the new graft and immuno-suppressant drug levels, the pulmonologist may also prescribe and review tests and administer medication if the patient develops an infection or is at risk for rejection.

Signs and Symptoms Show Medical Necessity

When problems are caused by medication, infection or the threat of rejection, properly coding the signs and symptoms is important until a definitive diagnosis is made. Those signs and symptoms can vary. Typical reactions include high fever (780.6) and high blood pressure (401.9), intense chest pain (786.5x), and a marked drop in urine output (788.5). More often, however, the symptoms are less dramatic, such as low-grade fever, decrease in urine output, pain and tenderness, and slight increase in blood urea nitrogen and creatinine levels (790.6, Other abnormal blood chemistry).

You must also use the correct primary code to indicate rejection of a transplanted lung (996.84), and secondary diagnoses for the complications that can result in rejection, such as cytomegalovirus infection (078.5), are necessary for appropriate reimbursement.

Remember to include V42.6 (Lung replaced by transplant) among the diagnoses when reporting post-transplant care.

Code 99233 Requires Special Care

Pulmonologists may prescribe high doses of steroids initially to treat suspected rejection symptoms. If a diagnosis is in doubt, a physician may investigate, using an ultrasound examination (76604, Ultrasound, chest, B-scan [includes mediastinum] and/or real time with image documentation) to detect pleural fluid collections, says Charlie Strange, MD, FCCP, director of the medical intensive care unit at the Medical University of South Carolina in Charleston.

Consider this scenario: Two weeks after undergoing a lung transplant, the patient, still in the hospital, exhibits a high fever and elevated blood pressure, slightly reduced urine output, and moderate chest pain when he breathes. The pulmonologist examines the patient and orders and reviews the results of a chest radiography and multiple blood tests. Because the chest radiograph shows pleural effusion, the physician performs a thoracentesis after ultrasound evaluation of the pleural space.

Based on this information, says Nancy DeMarco Lamare, CPC, CCS-P, a multispecialty coder for Central Maine Clinical Associates in Lewiston, in Monmouth, Maine, you should report 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ) because two of the three components a detailed history and high-complexity decision-making necessary for choosing that E/M level are present: The E/M code should be appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) because 99233 is being used on the same date of service as other reportable procedures.

Note that code 99233 includes the work associated with the examination and the review of the blood test results. You should report 76604 appended with modifier -26 (Professional component) if the pulmonologist interpreted the ultrasound results and prepared the report, Lamare says. The hospital will report the blood tests and the technical components of the ultrasound because it provided the staff and facilities for the procedures.

Finally, you should use 32000* (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) for the thoracentesis, which stands alone and does not require a modifier.

To prevent rejection, pulmonologists may prescribe high doses of steroids initially to treat suspected rejection symptoms. If a rejection episode does not respond to steroids, a bronchoscopy with transbronchial biopsy (31628, Bronchoscopy [rigid or flexible]; with transbronchial lung biopsy, with or without fluoroscopic guidance) can often provide a definitive diagnosis, Strange says. Ongoing rejection confirmed by biopsy can be treated by various biological antilymphocyte preparations.

The combination of immunosuppressive antibodies and a drug cocktail administered at the time of transplant has been largely successful in preventing rejection in most patients, despite high levels of donor-recipient incompatibility.

When side effects occur from immunosuppression, however, the E/M service code should be reported with the appropriate ICD-9 E codes (E930-E949) for drugs, medicinal and biological substances that cause adverse effects in therapeutic doses. The E code will be based on the specific drug causing the adverse effect. You should remember, however, that E codes should be used as secondary codes in conjunction with the codes for signs and symptoms.

For example, after transplantation, most physicians prescribe cyclosporine and tacrolimus, which can damage the kidneys at higher doses and lead to elevated blood creatinine levels. These drugs interact with many common medications. Blood levels may rise when pulmonologists use antifungal agents, or they may fall if anticonvulsants are prescribed. Therefore, physicians should monitor blood levels of these drugs, usually drawn as a 12-hour trough after the last dose.

You should report the appropriate-level E/M code (99211-99215 for outpatient care or 99231-99233 for inpatient care) based on the level of service provided, including interpreting the blood test results. If the pulmonologist saw the patient in the office and drew the blood for testing, you could also report G0001 (Routine venipuncture for collection of specimen[s]) for Medicare or 36415* (Routine venipuncture or finger/heel/ear stick for collection of specimen[s]) for private payers, Lamare says. If the blood draw is the only reason for the visit, then you should not report an E/M code.

If a separate identifiable service, such as an office visit, is performed, however, you should bill the E/M code and append it with modifier -25, Lamare suggests. These codes should be linked with any signs or symptoms ICD-9 codes along with E933.1 (Antineoplastic and immunosuppressive drugs) as a secondary diagnosis.

Modifier -24 Is Key for Follow-Up E/Ms

The transplant surgeon and the pulmonologist often work in concert after transplantation. The transplant surgeon, however, can bill follow-up services for specific items, such as immunosuppression, during the 90-day transplant global period only by attaching modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the E/M code. Because of the complexity of the patient's post-transplant condition, the pulmonologist could easily perform, document and report high-level visits (e.g., 99233, Subsequent hospital care; 99215, Office or other outpatient established patient visit) and use V58.69 (Long-term [current] use of other medication) as a secondary diagnosis to bill for immunosuppressive therapy in addition to any signs or symptoms present.

Some carriers do not recognize modifier -24 if reported during the same admission as the transplant. It may only be recognized postdischarge or for a subsequent hospitalization during the global period. Inpatient visits reported by the transplant surgeon during the same hospitalization with modifier -24 for immunosuppression therapy are an exception to this rule. If the transplant pulmonologist is not part of the surgeon's group practice, he or she can bill for follow-up visits without modifier -24 during the global period.

Don't Forget the Frequent Visits and Tests

After transplantation, the pulmonologist schedules frequent visits with the patient twice a week for several weeks to review laboratory data (creatinine, BUN and electrolytes) and to regularly check the patient's progress, side effects of medications and symptoms of infection. Lab work performed regularly, at least initially, includes creatinine levels and careful tracking of a patient's electrolytes, drug levels, glucose and cholesterol, potassium levels, calcium and phosphorus. To bill properly for these services, you should include the interpretation of the test results as part of medical decision-making's "amount and/or complexity of data reviewed" when assigning the E/M level.

Although the first two months after transplantation are especially crucial, the physician must continue to be watchful for the first year. If rejection occurs after the first year, frequently it's caused by the patient's failure to keep up with his or her immunosuppressive medication regimen. Such a setback may require additional consultations, which you should code as 99241-99245 (Office consultation for a new or established patient ) if the pulmonologist is no longer participating in the patient's care and the primary-care physician requests the consult. Otherwise, you should report 99211-99215 for an established patient office visit.

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