Primary Care Coding Alert

Question: A new patient reports to the FP complaining of wheezing and breathlessness. The physician conducts a level-three E/M service. Suspecting emphysema, the physician conducts a spirometry with graphic record and orders a myelography. How should I report this encounter?

Missouri Subscriber

 Answer: The answer depends on whether the physician confirms an emphysema diagnosis. The CPT codes will be the same regardless of the final diagnosis, but the ICD-9 codes will differ.

 Case 1 -- Confirmed diagnosis: Suppose the physician confirms a diagnosis of emphysematous bleb. On the claim, you should report the following:
 - 99203 (Office or other outpatient visit for the evaluation and management of a new 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.
 - 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for the spirometry.
 - 492.0 (Emphysematous bleb) linked to 99203 and 94010 to prove medical necessity for the encounter.

 Case 2 -- Inconclusive diagnosis: Suppose the tests 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.   Your claim should look like this:
 - 99203 for the E/M service.
 - 94010 for the spirometry
 - 786.05 (Shortness of breath) and 786.07 (Wheezing) linked to 99203 and 94010 to prove medical necessity for the encounter.