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Pulmonology Coding Alert

Anthrax Exposure:

From Onset to Critical Care

Published on Sat Dec 01, 2001

With the ongoing reports of biological terrorism saturating the media, many pulmonologists are experiencing an onslaught of patients who think they may have contracted anthrax. 
 
"We've had a rash of such patients come in with vague symptoms," says Cynthia DeVries, RN, CPC, coding and reimbursement specialist with Lee Physicians, a 140-physician practice in Fort Myers, Fla. The symptoms of anthrax are similar to those of the flu: fever, muscle aches and fatigue. "Because it is curable if recognized and treated early enough, many people who develop these symptoms come rushing into the office fearing the worst," DeVries says.
 
Pulmonologists should use the final diagnosis code for ill patients with fears of anthrax. For example, a patient whose asthma was exacerbated by a cold comes in afraid he or she has anthrax poisoning. Code the visit with 460 (acute nasopharyngitis [common cold]) as primary and an asthma code (493.2) as secondary. Link both diagnosis codes to the appropriate E/M office visit code, 99201-99215.
 
Regardless of the patient's fears, practices should code for the original symptoms, says Carol Pohlig, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania. When patients present with respiratory problems, believing they have anthrax, use the symptoms as the primary code. For example, if a patient presents with shortness of breath but the physician finds no infection, code 786.05 (shortness of breath) and an office visit code.
 
Some patients who have no symptoms schedule a visit because they are worried they were exposed. When no problem is found, bill these visits with V65.49 (health advice, education; other specified counseling) linked with the proper E/M code. Because the pulmonologist will probably spend time counseling the patient and educating him or her about anthrax, practices can use V65.49 for these visits, Pohlig says. Medicare probably will not cover it, but some private payers may.  
 
Critical Care

In the rare case that a patient is confirmed as having anthrax, he or she would be admitted to the intensive care unit (ICU) of a hospital. If the pulmonologist takes over care of the patient and begins critical care immediately, the appropriate critical care code (99291-99292) should be used, depending on the amount of time spent. For example, a postal worker who worked in a facility in which anthrax cases have been documented is admitted to the ICU with respiratory distress (786.09) and a temperature of 102 degrees F (780.6). A chest radiograph indicates a right perihilar infiltrate (793.1) and a small pleural effusion (511.9).
 
She is started on multidrug therapy, including ciprofloxacin, which was changed to azithromycin after 24 hours. She had an elevated white blood cell (WBC) (288.8) count of 11,000 with 14 percent bands. A CT scan shows a right pleural effusion, perihilar consolidation and mediastinal adenopathy (785.6). The pulmonologist performed two thoracenteses that produced serosanguineous pleural fluid and a bronchoscopy that showed grossly edematous bronchi. Both pleural fluid and bronchial biopsy were positive for B. anthracis (022.1) by IHC stain.
 
For these procedures, the pulmonologist should report the critical care code based on the amount of time he or she monitored the patient. Code 99291 is for the first 30-74 minutes of critical care, and 99292 is for each additional 30 minutes beyond the first 74 minutes. The pulmonologist would report 32000 (thoracentesis) twice for the two thoracenteses and 31622 (bronchoscopy [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]) for the bronchoscopy.
 
A patient who was exposed to anthrax but does not require constant bedside attendance right away may be placed in the intensive care unit (ICU). The pulmonologist would perform the admission service, using the initial hospital care codes, 99221-99223. If, later in the day, the patient deteriorates and the pulmonologist begins critical care, he or she can report the critical care codes as well. Both codes can be reported on the same day if the critical care began later and if modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is attached to the initial hospital care codes.

Pulmonologists as Consultants

In some cases, an emergency department (ED) physician may call a pulmonologist to consult on a suspected anthrax case because the patient has severe respiratory distress or is coughing up blood. The pulmonologist may begin diagnosing for anthrax by ordering a CT scan, a chest x-ray and blood culture. Because the physician is still evaluating the patient, bill the appropriate consultation code, 99241-99255.
 
If the patient is not coughing up blood, the pulmonologist may use aerosol or vapor inhalation to induce sputum. Report 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) for the initial inhalation therapy and 94665 ( subsequent) for subsequent. Bill these codes with the consultation code, attaching modifier -25 to the consultation code to illustrate that it is a separate service.
 
The physician would have to document his or her opinion in the patient's medical record and also communicate it in a written report to the requesting physician (in this case, the ED doctor).

Case Study

The following case study is taken from an actual instance of anthrax inhalation that occurred recently.
 
Source: Centers for Disease Control 

The Real-Life Case: An inhalation anthrax (022.1) case occurred in a 61-year-old woman who worked in the stockroom of a hospital in Manhattan. The patient became ill on Oct. 25 with malaise (780.79) and myalgia (729.1). During the next few days, she had shortness of breath (786.05), chest discomfort (786.59) and a productive cough with blood-tinged sputum (786.3). She reported no fever, chills or night sweats.
 
She presented to an emergency department on Oct. 28 in respiratory distress (786.09). Her temperature was 102 degrees F (39 degrees C) (780.6), and she was admitted to the ICU and required mechanical ventilation. Initial chest radiograph revealed pulmonary venous congestion (514) and bilateral pleural effusions (511.9). A chest computerized tomography (CT) scan revealed a widened mediastinum (519.3) and bilateral pleural effusions. An echocardiogram indicated a small pericardial effusion (420.90). She was empirically treated with levofloxacin, rifampin and clindamycin.
 
Blood cultures grew B. anthracis (022.3) less than 24 hours after admission. Her pleural effusion revealed hemorrhagic fluid and B. anthracis. The patient died on Oct. 31.

Coding the Case: Most likely a pulmonologist would admit the patient to the ICU. If the admitting physician does not start critical care immediately, the appropriate initial hospital care code (99221-99223) should be used, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a coding consulting company based in Lakewood, N.J. Also, the pulmonologist would start the mechanical ventilation (94656, ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day). But ventilation management cannot be billed with the initial admission service or a consultation because it is considered a component of these other services.
 
If the patient undergoes critical care immediately upon being admitted to the ICU, initial hospital care codes cannot be billed, Cobuzzi says. Code 94656 should also not be billed because it is considered part of critical care. The pulmonologist would bill the appropriate critical care code (99291-99292) based on the amount of time spent caring for the patient.
 
The pulmonologist may call in an infectious-disease (ID) physician for a consultation on the case. The ID physician might take blood cultures to identify if the anthrax is present in the patient's blood and take blood cultures to try to identify the organism causing the problem. The ID physician would charge the appropriate hospital consultation code, 99251-99255.
 
A radiologist would interpret the chest radiograph, which was taken by the hospital staff. This would be reported as 71010 (radiologic examination, chest; single view, frontal) or 71020 (... two views, frontal and lateral) depending on the number of views, with modifier -26 (professional component) appended. Interpretation of the CT scan would also be performed by the radiologist and reported with 71250 (computerized axial tomography, thorax; without contrast material) with modifier -26.
 
A cardiologist would interpret and report the electrocardiogram with 93010 (electrocardiogram, routine ECG with at least 12 leads; interpretation and report only). Because the hospital would take the ECG but the cardiologist would interpret it, he or she can use 93010, Cobuzzi says. The pulmonologist and/or ID physician may look at the chest x-ray, CT scan and ECG to apply the results toward their medical decision-making, but they cannot bill for this.
 
A complication that may have occurred in this case is the loss of a venous access, Cobuzzi says. The attending physician would have to call a general surgeon for a consult if this happened. The general surgeon would place a central venous catheter and bill 36489 (placement of central venous catheter). He or she would also bill a consultation code (99241-99245) appended with modifier 25.
 
Note: In some hospitals, the pulmonologist will place the central venous catheter and bill 36489.

The Vaccine

When the anthrax vaccine becomes more available, coders should assign two codes:

  • 90581 anthrax vaccine, for subcutaneous use; and for its administration:
  • 90471 immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration); one vaccine (single or combination vaccine/toxoid).

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