Pulmonology Coding Alert

Remember that ARDS is secondary to COVID-19.

Your pulmonologists are likely to address cases of adult respiratory distress syndrome (ARDS) now more than ever. These conditions can be related to COVID-19, or they may present due to lung injuries or other issues. However, there’s more to treatment beyond ventilatory management and critical care. Knowing the additional work involved for the pulmonologist can ensure proper reimbursement for all the services provided.

Check out the following tips to ensure that you’re reporting your ARDS services correctly every time.

Diagnosing ARDS

To diagnose ARDS, pulmonologists may order several tests and procedures, including arterial blood gas (ABG) studies (36600, Arterial puncture, withdrawal of blood for diagnosis, or 36620, Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous), chest X-rays (71045-71048), and occasionally, pulmonary artery catheterization (93503, Insertion and placement of flow directed catheter (e.g., Swan-Ganz) for monitoring purposes).

During the diagnosis phase, you should not report ARDS (J80, Acute respiratory distress syndrome) to show medical necessity for the tests and procedures. Instead, you should report the signs and symptoms the patient exhibits because the pulmonologist is not sure of the final diagnosis at this time. These symptoms can include shortness of breath (R06.02), respiratory failure (J96.x), pneumonia (J18.x), or sepsis (A41.9).

Once the pulmonologist has made the ARDS diagnosis, you can use J80 to show medical necessity for the tests and treatments needed thereafter. However, always keep sequencing in mind during this period, because if the ARDS is due to another condition, that other ICD-10 code might be listed as the primary diagnosis, and ARDS could be listed secondary. Such is the case when ARDS is due to COVID-19, in which case you’d report U07.1 (COVID-19) as your primary diagnosis and J80 as the secondary code.

Because the hospital and other professionals aligned with the facility perform and interpret these tests and procedures, the pulmonary physician cannot bill for them. However, the pulmonologists will review the test and procedure results and discuss the findings with the professionals who conducted them (particularly the intensivist who may perform the pulmonary artery catheterization). The pulmonary physician’s documentation of their discussion with other healthcare professionals may be used to calculate the medical decision making portion of the inpatient E/M services (99221- 99223, 99231-99233) or when determining the critical care time (99291-+99292).

Coding ARDS Treatment

Pulmonologists use several methods to treat ARDS in the ICU, including initiating and managing ventilation (94002-94004) and continuous positive airway pressure (94660-94662). The goal is to support the patient’s breathing while their lungs heal.

Usually, the ventilation tube is inserted through the mouth or nose. If the pulmonary physician intubated the patient, they could report 31500 (Intubation, endotracheal, emergency procedure). Occasionally, however, the pulmonologists will perform a percutaneous tracheostomy (31600, Tracheostomy, planned (separate procedure)) to ensure a safe airway, especially if the patient has been on the ventilator for several days and appears to need long-term ventilation.

For example, a patient who had an automobile accident that resulted in a severe blow to the chest when they hit the steering wheel is admitted to the ICU. The patient exhibits significant shortness of breath. The attending intensivist requests the opinion of a pulmonary physician, who subsequently orders an ABG and a chest X-ray and determines that the patient has ARDS. They intubate the patient and initiate ventilation management.

To report these services, you should bill an inpatient consultation code if your payer allows it (e.g., 99255, Initial consultation for a new or established patient …) linked with J80. You should also report 31500. Append 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) to the inpatient consult code to show it is a separate service from 31500.

Bundling alert: Keep in mind that you cannot report initiating the ventilation management (94002) separately because it is bundled into the inpatient consultation by the National Correct Coding Initiative (NCCI). Any subsequent care the pulmonologist provides should be billed with the subsequent inpatient care (99231-99233) or critical care codes (99291-+99292), depending on the services provided and the patient’s condition.

In addition to various ventilation treatments, pulmonary physicians may administer medications to reduce anxiety and discomfort and help conserve the patient’s energy. The physician may also prescribe drugs to reverse the underlying condition if possible, to prevent and treat complications, and to alleviate patient distress, such as pain, air hunger, anxiety, and severe confusion.

ARDS Care Is Usually Critical Care

Because ARDS patients are often critically ill, the services the pulmonologist provides in the ICU should likely be reported as critical care (99291-+99292), if the documentation satisfies all the requirements for providing such care.

Critical care is a time-driven service, and the codes are used to report the total duration of time spent by a physician even if their time is not continuous. Therefore, the billing provider must document the cumulative, daily time they personally spent in treating the patient, regardless of whether the physician is at the bedside or on the floor or unit.

For example, the pulmonologist spends 80 minutes providing critical care to an ARDS patient in the ICU, performing an examination, ordering and reviewing tests, making treatment decisions, and providing care. As part of the treatment, the physician spends 10 minutes of this time intubating the patient to begin ventilation management.

To report the pulmonologist’s services, you would bill 31500 for the intubation. You would also report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care services. You could not bill +99292 (… each additional 30 minutes (List separately in addition to code for primary service)) because the total time for critical care does not meet or exceed 75 minutes. You would subtract the 10 minutes for the intubation from the critical care time, leaving only 70 minutes. In addition, you’ll append modifier 25 to 99291 to indicate that it is separately identifiable from the intubation.

What About Other E/M Coding?

Although the ARDS patient may be in the ICU, that physical location does not automatically mean that the pulmonologist’s services are considered critical care (see our article on critical care later in this issue). If the patient does not meet the requirements listed above, you should report the physician’s services with the inpatient E/M codes (99221-99223 for initial hospital care, or 99231-99233 for subsequent hospital care).

You should consider any time the pulmonologist spends reviewing the patient’s test results or discussing them with the hospital’s cardiologist and radiologist when determining the level of medical decision making. You should also keep in mind that if the physician does not have access to the patient’s history because the patient is unconscious, there are no records, or caretakers do not know the medical history, you can get full credit for a comprehensive history if the pulmonologist documents these facts.