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). 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 (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. Coding ARDS Treatment 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 [...]