Pulmonology Coding Alert

If you are intimidated by wading through the 3,500 new code pairs that the Correct Coding Initiatives just introduced, you are not alone. Eli helps you cut to the chase with what pulmonology coders need to know about the CCI 15.2 edits, effective July 1.

In a nutshell: The CCI edits are pairs of procedure codes with prohibited or limited reimbursement when reported together for the same patient on the same day by the same provider, according to Frank Cohen, MPA, senior analyst with MIT Solutions Inc. in Clearwater, Fla., in his June 30, 2009, webinar "NCCI Version 15.2 Update."

Watch out: Continued violation of CCI edits or inappropriate modifier use can increase your chances of auditor review, particularly under RACs (recovery audit contractors), says Cohen. So toe the line, and refer to the date of service -- not the claim submission date -- when applying these changes.

Read on for the skinny on the codes you may use.

In a typical pulmonology practice, you will probably need to concern yourself with only two new code pairs.

Pair 1: CCI 15.2 prohibits the reporting of a subsequent IV push along with spirometry with bronchodilation. Therefore, avoid reporting the following two codes together:

• 94060 -- Bronchodilation responsiveness, spirometry as in 94010, pre- and postbronchodilator administration

• 96376 -- Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular, each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure).

Note that previous CCI edits also prohibit coding 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular), 96374 (... intravenous push, single or initial substance/drug) or 96375 (... each additional sequential intravenous push of a new substance/drug [List separately in addition to code for primary procedure]) to report an injection along with 94060. Thus, incorporating the current edit for 96376 allows for consistency when handling therapeutic, prophylactic, or diagnostic injections, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

All of the above codes have a "1" in the modifier column, meaning that you can override the edit when appropriate. The situation, however, may rarely present itself. "I am not sure anyone would ever give an initial IV push of any drug during spirometry, let alone a subsequent one," comments Alan L. Plummer, MD, professor of medicine, division of pulmonary, allergy, and critical care at Emory University School of Medicine in Atlanta.

Pair 2: Starting from July 1, you must also avoid reporting 36000 (Introduction of needle or intracatheter, vein) for IV access along with 96376 for a subsequent IV push.

Know when a loophole can pay off. If the modifier column contains a "0," you cannot override the bundle. However, if the modifier column contains a "1" you can unbundle the pair by using modifier 59 (Distinct procedural service) when appropriate, notes Plummer.

Example: There are several scenarios which may necessitate the unbundling of 36000 and +96376 (subsequent IV push), shares Barbara J. Cobuzzi, MBA, CPC,CPC-H, CPCP, CENTC, CHCC, senior coder and auditor for The Coding Network and president of CRN Healthcare Solutions in Tinton Falls, N.J. Append modifier 59, says Cobuzzi, if the pulmonologist:

• Introduces a new needle or intracatheter at a different site, or

• Performs the two procedures during different operative sessions or patient encounters on the same day.

Example: An established patient with an acute asthmatic attack arrives at the office. The pulmonologist orders albuterol administered by nebulization, starts an IV, and administers Solu-Medrol intravenously. The IV infiltrates and then is removed. The patient improves after two more albuterol treatments. Before allowing the patient to leave the office, the pulmonologist starts another IV and administers another IV dose of Solu-Medrol. In this example, says Plummer, you should code:

• 99211-99215 (Office or Other Outpatient Services, Established Patient) for the office visit

• 36000-59 for the initial (failed) access

• 96374 for the initial IV dose of Solu-Medrol

• 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) for the initial albuterol nebulizer therapy

• 94640-76 (Repeat procedure or service by same physician) x 2 for the subsequent albuterol treatments • 96376 for the subsequent IV push of Solu-Medrol in the second access site.

• You should also code for the two doses of Solu- Medrol, depending on the amount used: J2920 (up to 40 mg) or J2930 (up to 125 mg), adds Pohlig.