Pulmonology Coding Alert

Careful: 94375 is hot on bundles.

Combat these three common mistakes in reporting extrinsic allergic alveolitis, and your claim will soar to success.

Say a patient presents with fever, muscular aches, dry cough, shortness of breath, and a general feeling of being unwell. Although these symptoms could lead your pulmonologist to report extrinsic allergic alveolitis (495.x), it may not be the appropriate ICD-9 code. Digging deeper than the tip of the iceberg means your physician should take several steps to properly diagnose this condition, but the whole process could leave you dazed and confused.

Mistake #1: You Overlook E/M Encounter

Extrinsic allergic alveolitis (495.x) is a lung disorder resulting from repeated inhalation of organic dust, usually in a specific occupational setting, otherwise known as hypersensitivity pneumonitis. In diagnosis, the best evidence for this condition is the patient's occupation and a history of exposure to animal or vegetable dusts.

The doctor may want to do some tests to verify the diagnosis, including spirometry (94010), flow volume loop (94375), lung volume (94240), diffusing capacity (94720), and pulse oximetry (94760), antigen challenge test (94070, 95071) and blood test (86001, 85025). With these many codes involved, how would you know which one should make it to your report?

Hold that thought: Before you even consider any one of these codes, chances are your pulmonologist would have initially performed an E/M service. If the doctor's notes indicated that she performed this service, then you should bill the appropriate level of E/M care. Because the diagnosis requires a detailed and careful history that would include social, environmental, and occupational status, a high-level office visit code may be necessary (i.e., 99204, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family; and 99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family).

Caveat: Billing pulse oximetry (94760, Noninvasive ear or pulse oximetry for oxygen saturation; single determination) on the same day as any other billable service would be a no-no since the 94760 "T-status" bundles the corresponding payment into all other same-day payments.

Mistake #2: You Charge All Tests For The Provider

Besides the E/M code, you may report some of the tests that the pulmonologist may have ordered, including:

Watch out: Use caution when reporting the laboratory test (86001, Allergen specific IgG quantitative or semiquantitative, each allergen; 85025, Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count). You can bill this service only if your office is certified to process and analyze the specimens.

In the same vein, don't bill prolonged postexposure evaluation (94070) and antigen challenge test (95071) for your pulmonologist unless these pulmonary function tests (PFTs) are performed in the physician's privately owned PFT lab. If the PFTs took place in a hospital-based PFT laboratory, then you would report only the professional components of the service by appending modifier 26 (e.g., 94070-26). The facility-based lab reports the technical components (94070-TC, 95071), says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

Mistake #3: CCI Bundles Get Past Your Radar

If the pulmonologist orders both spirometry (94010) and flow volume loop (94375, Respiratory flow volume loop) as diagnostic tests, you would have to leave 94375 off your claim.

Why: CPT 94375 is a column 2 code for 94010, which means you cannot bill these codes together under any circumstances. Non-Medicare insurance carriers may allow payment but, you should check with payers first about their policy.

Also, 94375 is a component of the antigen challenge test 94070. While you should not report them together on the same day, the Correct Coding Initiative (CCI) edits allows a modifier to differentiate between the services provided for separate reasons during separate sessions on the same day.

Another code that bundles into 94070 is 94010 (spirometry). The only time you would report these codes separately is when the pulmonologist orders spirometry for a separate and distinct reason. For instance, the physician orders 94010 as the first test, but the results indicate a problem that requires additional testing. The physician then orders prolonged postexposure evaluation (94070) as a second test. In such cases, you would report attach modifier 59 (Distinct procedural service) to 94010 to show that this CPT is distinct from 94070.