Otolaryngology Coding Alert

Your diagnosis choice is simple, but procedures can cross up.

Most allergy patients your otolaryngologist sees in the springtime might be treated for seasonal conditions, but don’t forget about another allergy situation: extrinsic allergic alveolitis, or EAA (495.x). 

Several steps and multiple options are available when coding for EAA. Read on for details on how to successfully report the condition.

What it is: Patients with EAA have lung and airway inflammation because of repeated inhalation of organic antigens in dusts (such as from dairy or grain products or animal dander). Another name for EAA is hypersensitivity pneumonitis. Acute and subacute forms of EAA can cause recurrent pneumonitis; chronic disease can cause fibrosis, emphysema, and permanent lung damage.  

Start With an Appropriate E/M Code

Scenario: To test a patient for EAA, the physician orders several pulmonary function tests (PFTs), including spirometry (94010), flow volume loop (94375), lung volume (94726/94727), diffusing capacity (94729), and pulse oximetry (94760). He also orders an antigen challenge test (94070, 95071) and a blood workup (86001, 85025). 

Some ENT practices will conduct these tests themselves, but others will refer the patient to a pulmonologist. If you’re coding for the tests, your first step is to choose the most appropriate E/M code. You might be able to report a higher-level E/M service such as 99204 for a new patient or 99214 for an established patient because of the depth of exam and medical decision-making.  

Remember: You cannot bill pulse oximetry (94760, Noninvasive ear or pulse oximetry for oxygen saturation; single determination) on the same day as a physician-performed E/M service. The Medicare Physician Fee Schedule assigns 94760 a status “T,” which means the pulse oximetry is bundled into any other service performed that day. 

Be Wary of Lab Test Coding 

You can only bill for lab tests 86001 (Allergen specific IgG quantitative or semiquantitative, each allergen) and 85025 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count) if your office is certified to process and analyze the specimens. 

Silver lining: You can, however, report some of the other tests in addition to the E/M service. In the scenario above, these include: 

• 94070 – Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents (e.g., antigen[s], cold air, methacholine)
  
• 95071 – Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with antigens or gases, specify
  
• 94726 – Plethysmography for determination of lung volumes and, when performed, airway resistance
  
• 94727 – Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes
  
• +94729 – Diffusing capacity (e.g., carbon monoxide, membrane) (List separately in addition to code for primary procedure).
  

Place of service note: How you code for the above services depends partly on where the tests took place. For example, if your provider administered the prolonged post-exposure evaluation (94070) and antigen challenge test (95071) in the hospital, you can only report the professional portion(s) of the service. This means that the physician must append modifier 26 (Professional component) to the procedure code (94070). The facility will report the technical component.

You can report the entire service if your provider conducts the tests in his own office (place of service 11). 

Watch for Coding Bundles

Although the Physician Fee Schedule designates 94375 (Respiratory flow volume loop) as status “A,” you should not bill for the procedure in this scenario. Status A means the procedure is payable, unless the Correct Coding Initiative (CCI) bundles it with other services performed on the same day. In this case, 94375 is subject to two edits.

Bundle 1: Medicare will not pay for both 94010 and 94375. Code 94375 is considered a component of 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation).

Check with non-Medicare payers to determine if they will allow payment for 94010 and 94375 billed on the same day.

Bundle 2: CCI also bundles 94375 into 94070. You cannot report both services unless your provider performed them independently for separate reasons. 

Spirometry note: You also should not report 94010 because CCI bundles it into the more-comprehensive 94070 code. The only time you would report this code separately is when the physician orders spirometry for a separate and distinct reason. For example, if 94010 is the first test done, and it indicates a problem that requires additional testing with the prolonged post-exposure test (94070), you would code this scenario as 94070, 94010-59 (Distinct procedural service). 

You would use XU (Unusual non-overlapping service. The use of a service that is distinct because it does not overlap usual components of the main service) instead of the 59 for a Medicare patient once you convert to the new “X” modifiers slated to replace the 59 modifier.  The reason that XU is appropriate is that the 94010 and 94070 are non-overlapping but serial procedures, one performed after the other, with the medical necessity determined by the first.

Finalize Your Code List

For the scenario above in a non-facility setting (Office), the provider reports the highest-valued procedure first and lists the other procedures next:

• 992xx for the E/M service
• 94070 for prolonged post-exposure evaluation
• 95071 for antigen challenge test
• +94729 for diffusing capacity 
• 94726 and/or 94727 for lung capacity tests.

Modify it: Some payers may require modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) with the 992xx because CCI added that xxx global period procedures include a small E/M component back in version 7.2. If your payer adopts that stance, verify that the documentation demonstrates that the E/M service is above and beyond the very small E/M service defined for minor services.