Internal Medicine Coding Alert
Confirm/Deny Emphysema Dx, Then Choose Code
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Question: During an initial consultation with a new patient complaining of wheezing and breathlessness, the internist suspects emphysema. After a level-three consult, the internist performs a spirometry with graphic record and a myelography and sends the patient home. How should I report this scenario? Pennsylvania Subscriber Answer: The CPT codes will be the same regardless of the tests' outcomes. Your diagnosis coding will depend on whether the internist confirms a diagnosis of emphysema. Option 1 -- Definitive diagnosis: Suppose the physician confirms a diagnosis of emphysema. On the claim, you would report the following: • 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measure-ment[s], with or without maximal voluntary ventilation) for the spirometry. • 70010 (Myelography, posterior fossa, radiological supervision and interpretation) for the myelography. • 99243 (Office consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of low complexity) for the E/M service. • modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) attached to 99243 to show that the E/M and other services were separate. • 492.x (Emphysema) linked to 94010, 70010 and 99243 to prove medical necessity for the encounter. Case 2 -- Inconclusive diagnosis: After the tests, the results are inconclusive or negative for emphysema. Consequently, you should rely on the signs and symptoms to support medical necessity for your physician's services. On the claim, you would list the following: • 94010 for the spirometry. • 70010 for the x-ray. • 99243 for the E/M service. • modifier 25 attached to 99243 to show that the E/M and other services were separate. • 786.05 (Shortness of breath) and 786.07 (Wheezing) linked to 94010, 70010 and 99243 to prove medical necessity for the encounter.
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