Pulmonology Coding Alert

There is more to coding for adult respiratory distress syndrome (ARDS) than just ventilatory management and critical care. Knowing the additional work involved for the pulmonologist can ensure proper reimbursement for all the services provided.

ARDS is a severe form of lung dysfunction that is caused by direct injury to the lungs. (For more on "What Is ARDS?" see page 67.) Pulmonologists most often diagnose and treat this disorder in a hospital's intensive care unit (ICU).

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 (71010-71035) 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 (518.5, 518.82) 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 (786.05), respiratory failure (518.81), pneumonia (486) or sepsis (038.9).

Once the pulmonologist has made the ARDS diagnosis, you can use 518.5 or 518.82 to show medical necessity for the tests and treatments needed thereafter. 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 his or her 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).

"Time may be used when reporting E/M services," says Mary Mulholland, RN, BSN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. Remember to document not only the time the pulmonologist spends providing care at the bedside but also the time he or she spends reviewing charts and revising the plan of care, Mulholland reminds. Such services are reportable as long as the doctor performs them while on the unit or floor.

Pulmonologists use several methods to treat ARDS in the ICU, including initiating and managing ventilation (94656, Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day; and 94657, subsequent days) and continuous positive airway pressure (94660, Continuous positive airway pressure ventilation [CPAP], initiation and management), says George A. Sample, MD, FCCP, a representative to the AMA CPT Advisory Committee for the Society of Critical Care Medicine. The goal is to support the patient's breathing while his or her lungs heal.

Usually, the ventilation tube is inserted through the mouth or nose. If the pulmonary physician intubated the patient, he or she 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 he hit the steering wheel is admitted to the ICU. He 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. She intubates the patient and initiates ventilation management.

To report these services, you should bill an inpatient consultation code (e.g., 99255, Initial inpatient consultation for a new or established patient ) linked with 786.05. You should also report 31500 linked with 518.5 because the pulmonologist intubated the patient. You should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the inpatient consult code to show it is a separate service from 31500. Also, you cannot report initiating the ventilation management (94656) separately because it is bundled into the inpatient consultation by the Correct Coding Initiative (CCI). Any subsequent care the pulmonologist provides should be billed with the subsequent inpatient care (99231-99233) or critical care codes (99291-99292), Mulholland says, 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. Pulmonologists frequently use antibiotics to treat confirmed or suspected infections, vasopressors like dopamine to maintain adequate blood pressure, and pain relievers like morphine and anti-anxiety drugs to improve the patient's tolerance of ventilation.

Because ARDS patients are frequently critically ill, the services the pulmonologist provides in the ICU should likely be reported as critical care (99291-99292). If the pulmonologist satisfies all the CPT requirements for providing such care, he or she can expect much higher payment than by reporting the individual treatment options, such as ventilator management (94656) or a subsequent hospital visit (99231-99233), Sample says. (For a more detailed discussion of critical care coding, see the article "Critical Care Can Raise Payment for Acidosis Treatment" in the July 2002 Pulmonology Coding Alert.)

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 his or her time is not continuous. Therefore, the billing provider must document the cumulative, daily time he or she personally spent in treating the patient, regardless of whether the physician is at the bedside or on the floor or unit.

Time spent in activities outside the patient's unit or off the floor may not be reported as critical care. In addition, if the pulmonologist performs separately reportable services, such as intubation, he or she may not include that time when determining critical care billing.

For example, the pulmonologist spend 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 for the critical care services. You could not bill 99292 because the total time for critical care does not meet or exceed 75 minutes. You would subtract the 10 minutes for the intub-ation from the critical care time, leaving only 70 minutes. And, you should append modifier -25 to 99291 to indicate that it is separately identifiable from the intubation.

Keep in mind that ventilator management (94656-94657) and CPAP (94660) are bundled into 99291 and 99292 as they are with all E/M codes by CCI. But, according to CMS' 2002 Physician Fee Schedule, 99291 carries 4.00 work relative value units (RVUs) and 99292 has 2.00 RVUs, whereas 94656 has 1.22 RVUs and 94657, 0.83 RVUs. Similarly, 94660 has 0.76 work RVUs. Higher RVUs result in higher reimbursement.

If you have not spent at least 30 minutes of care directed toward the patient and have not fulfilled the requirements of critical care, you cannot bill for this service. Reporting ventilator management and CPAP or a subsequent hospital visit remain as options. CCI, however, does not bundle the endotracheal tube placement (31500) into critical care or ventilator management, and the procedure may be reported separately.

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. 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 patient's medical history, you can get full credit for a comprehensive history if the pulmonologist documents these facts.

As with the critical care codes, ventilator management and CPAP are bundled into 99221-99233. Therefore, you cannot report them separately. Again, the RVUs for inpatient care ranging from 0.64 to 2.99 are generally higher than those for ventilator management and CPAP.