Internal Medicine Coding Alert

Signs-and-symptoms coding is key to solid claims

Now that sickle-cell disease patients are living longer, they're increasingly choosing internal medicine practices for primary care. If your internist diagnoses a sickle-cell patient with acute chest syndrome (ACS, 517.3), you'll need to know how to code initial exams, such as x-rays and bone scans, along with signs and symptoms.

1. Understand Initial Exams With Coding Scenario
 
Although ACS strikes many sickle-cell patients, your internist may run a variety of tests to ensure the patient doesn't have another respiratory problem, such as pneumonia (480.x, Viral pneumonia).
 
Example: A sickle-cell disease (282.6x) patient presents to your internist with shortness of breath (786.05), rib wall tenderness (786.59), chest pain (786.5x), difficulty breathing (786.09) and fever (780.6).
 
Your physician obtains a comprehensive history, performs a comprehensive exam, which includes reviewing all organ systems, and orders and interprets x-rays, which indicate new infiltrates on the lung (518.3, Pulmonary infiltrates).
  
And, your physician may review sputum results (89220, Sputum, obtaining specimen, aerosol-induced technique [separate procedure]) and bone scans (78300, Bone and/or joint imaging; limited area), says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia.
 
Generally, you should include the review of the sputum analysis and bone scans with the E/M service (99201-99205, 99211-99215). The facility that owns the equipment would report 78300 (bone scan).
 
If your practice owns equipment to perform bone scans and your physician interprets the results, you could report 78300. Nationally, Medicare pays $140 for the code.

2. Link 786.5x, 786.59 to Justify X-Rays

How you code the x-ray services depends on who performs the work and reads the films.
 
If the internist owns the equipment, you can report the global radiological code, such as 71020 (Radiologic examination, chest, two views, frontal and lateral). This code includes both technical and professional components.
 
Link the above signs and symptoms, such as chest pain (786.5x) and rib cage tenderness (786.59, Chest pain; other), to 71020, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.
 
But if a radiologist performs the x-ray and interprets the films, you can't report 71020. If, however, your physician ordered a report and reviewed the radiologist's findings, you may consider this a component of your physician's medical decision-making.
 
If your internist performed a comprehensive history and exam and engaged in high-complexity decision-making, you may code the appropriate E/M code (for example, 99215, Office or other outpatient visit ... established patient ...).
 
Helpful: Your internist's documentation should include notes of all the work he performed, such as reviewing x-rays and examining all the body systems, to justify the level of E/M service.

3. List Sickle-Cell Code First

After your internist diagnoses a patient with ACS, don't let all of the physician's follow-up care go to waste by listing 517.3 (Acute chest syndrome) as the primary condition.
 
To medically justify follow-up services, you should list an ICD-9 code for sickle-cell disease in crisis, such as 282.42 (Sickle-cell thalassemia with crisis) as the primary condition, and then use 517.3, according to ICD-9 guidelines.
 
Example: The physician delivers continuous positive airway pressure ventilation (94660, Continuous positive airway pressure [CPAP] ventilation, initiation and management) to the ACS patient in the hospital.
 
You would link the appropriate sickle-cell code (for example, 282.62, Hb-SS disease with crisis) to 94660 as the primary condition. You would report 517.3 as a secondary diagnosis.
 
Watch out: Medicare generally will not pay for both 94660 and an E/M service (for instance, subsequent hospital care, 99231-99233) unless the internist performed an office visit that was unrelated to the ventilation treatment, says Debby Wentzell, CPC, practice manager for Sentara Medical Group, a multi-specialty clinic that includes internists in Norfolk, Va.