Pulmonology Coding Alert

In Program Memorandum B-01-28 dated April 19, 2001, Medicare announced a revision of its definitions of physician supervision of diagnostic tests. To receive maximum reimbursement, pulmonologists and coders need to be aware of the three levels general, direct and personal and their application to pulmonology diagnostic procedures as specified by HCFA. These new definitions will go into effect on July 1, 2001.

HCFA explained that for these tests to be considered reasonable and necessary, and therefore covered under Medicare, they have to be performed under the supervision of an individual meeting the definition of a physician as defined by the Social Security Act and adapted in the Medicare physician fee schedule final rule of Oct. 31, 1997. To clarify the meaning of supervision, HCFA has revised the definition of the level of the involvement of the physician to include the following three:

General Supervision The diagnostic procedure is performed under the physicians overall direction, but his presence is not required during the actual performance of the test, although he should be available by phone or beeper. He is, however,responsible for training the nonphysician professional who conducts the test as well as for the continued maintenance of the equipment and supplies needed. For the pulmonologist, proceduressuch as spirometry; measurement of breathing capacity, thoracic gas volume, or expired gas collection; determination of airway closing volume or resistance to air flow; and pulmonary stress testing fall under this level of supervision.

Direct Supervision The physician must be present in the office area and be immediately available to offer guidance and direction if either is needed during the performance of the diagnostic test. His presence, however, is not required in the room during the test. For the pulmonologist, this category involves such diagnostic tests as bronchospasm evaluation in response to CO2 or hypoxia, or spirometric evaluation requiring the use of bronchodilators, antigens, or methacholine.

Personal Supervision The physician is required to be in the room during the performance of the procedure. Note: According to the list of procedures and their codes provided by Medicare, none of the diagnostic tests performed by the pulmonologist fall in this category.

Most of the procedures in the general category require the use of a machine only to provide a printout, which is then evaluated by the supervising pulmonologist to arrive at a diagnosis. These tests are not so specialized or invasive that they require the administration of drugs or direct monitoring by a pulmonologist.

Thus, for example, a 45-year-old smoker complaining of shortness of breath, difficulty in breathing, and a cough is referred by her family physician to a pulmonologist. When she arrives for her initial visit, the physician performs a spirometry to establish her pulmonary function, and the resulting printout is evaluated by the physician as he makes his initial diagnosis. This procedure would be coded using 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). As such, the level of supervision by the physician is general. He is responsible for the maintenance of the equipment, in this case, the spirometer; for the supplies needed to perform the test; and for training the staff performing it. Once he has determined the level of competency of his staff, he does not need to directly or personally oversee the procedure; his role is to read and evaluate the printout.

However, suppose the same patient requires a bronchospasm evaluation instead of only a routine spirometry to determine the cause of her symptoms. She may be exposed to various agents, among them antigens, cold air, and methacholine, with a spirometry given after each. This procedure involves more specialized diagnostic tools, including injections and exposure to substances that potentially could trigger a reaction in the patient. Since this is the case, the procedure is coded as 94070 (prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics), which requires the more involved direct supervision of the pulmonologist. In addition to being comfortable with the staffs competency, he needs to be in the office area so he can offer immediate and direct intervention (i.e., in this case, if the patient should have an adverse reaction to any of the substances).

This differentiation, according to Melissa Kersnick, CPC, a coder at Louisville Pulmonary Care, a clinic with seven pulmonologists in Kentucky., appears to be the one used to determine whether a diagnostic procedure is general or direct supervision. One merely involving a technical procedure appears to require general supervision while one involving the inhalation of a bronchodilator before a spirogram as in 94060 (bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]) or exposure to carbon dioxide as in 94400 (breathing response to C02 [C02 response curve]) requires the availability of the pulmonologist, probably because of possible side effects.

She goes on to say that this also explains why no diagnostic procedure falls into the personal supervision category; most pulmonology tests, given their nature and use, do not require the doctors attention.

These new definitions should have very little effect on the way pulmonology coders bill for Medicare reimburse-ment for these procedures. According to Kathleen Carne, CPC, a coder for pulmonology and critical care services, a practice including 15 pulmonologists in Troy, N.Y., the new Medicare designations should give coders few problems because they are clear and, for the most part, they reflect the current way these diagnostic tests are handled in the office setting.

Ensure Correct Code Usage

In the previously identified supervision guidelines for specific pulmonary procedures, you may have noted that the codes listed include technical components (i.e., services that do not involve physician work). When services involving these codes are provided, make sure that the correct CPT code is reported.

There are two considerations that you should be aware of to ensure prompt and full reimbursement from Medicare:

1. Reporting Global or Component Codes
If you are not billing for the entire service (which includes the technical and professional portions), report the appropriate code with a modifier appended to describe the portion of the service rendered.

For example, technical component (-TC) charges, depending on the place of service, are sometimes institutional charges and are not billed separately by physicians. This occurs when the service is provided in an outpatient hospital where the physician does not employ the staff or own the equipment. The only charge reported by the doctor would be 94010 with modifier -26 appended to indicate the professional component. The facility bills 94010-TC.

If services are provided in an office setting, where the physician owns the equipment, 94010 which encompasses the -TC and -26 portions is reported. Be careful not to add a modifier when it is not required. For example, the three transtelephonic spirometry codes each represent a specific portion of the service. Code 94014 is for the global service which includes the technical and professional components. Code 94015 is the -TC portion and 94016 is used for the professional component.

For example, on referral of her family physician, a 30-year-old patient complaining of a cough presents to the pulmonologist. She is given an aerosol inhalant to enable her to produce a sputum determining the cause. This procedure would be coded using 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation); however, no -TC modifier is needed because there is no physician work involved in this service.

2. Identifying Nonreimbursable Charges
The services outlined for supervision revisions may or may not be separately reimbursable by Medicare. Some of the identified codes may be bundled into other services rendered on a particular date of service. Pulse oximetry is an example of such a scenario.

According to the Physicians Fee Schedule, 94760 (noninvasive ear or pulse oximetry for oxygen saturation; single determination), 94761 (... multiple determinations [e.g., during exercise]) and 94762 (... by continuous overnight monitoring [separate procedure]) have been assigned a T status, indicating that, as for injections, these codes would be bundled with any other E/M service provided on the same day.

For example, a patient complaining of shortness of breath and difficulty in breathing presents to the pulmonologist. A detailed medical history is taken, and he is given a detailed examination, including a pulse oximetry. The physician spends 30 minutes with the patient discussing his symptoms and a course of treatment.

In this situation, the oximetry code, 94760 would be bundled with 99203 (office or other outpatient visit) for the E/M of a new patient requiring a detailed history, and examination, and medical decision-making of low complexity.

Note: Supervision guidelines must be maintained even though payment for 94760 is bundled into 99203. The level of supervision required for each procedure carried out on a particular date of service is not affected by its reimbursement status.

A Few Words About Documentation

Documentation is important for coding these diagnostic procedures. For those requiring general supervision, the files of the employees administering the procedure should contain a notation indicating that they have successfully completed the necessary training. In addition, the printout from the procedure should be placed in the patients chart. For those procedures requiring direct supervision, the progress notes should contain either a comment or a co-signature by the physician, or the individual administering the test should write a statement indicating that the service was provided under the direct supervision of the pulmonologist.