Pulmonology Coding Alert

Keep your CCI edits in mind for PFT bundles.

When a patient presents with common respiratory conditions, your pulmonologist should perform an extensive history and examination, and may order several diagnostic tests before he can settle with a definite diagnosis to report in the claim. Along with the primary diagnosis (if achieved), you should report the patient's signs and symptoms or else risk an audit.

Consider this scenario: The pulmonologist sees a patient for fever, shortness of breath, chest pain, weight loss, and fatigue. After undergoing a detailed history and examination, the patient becomes suspect for hypersensitivity pneumonitis, otherwise known as extrinsic allergic alveolitis (495.x). The physician orders a diagnostic bronchoscopy with fluoroscopic guidance, as well as a spirometry to verify the patient's condition.

To justify each service performed by the same provider or group, you might be accumulating payer inquiries or denials. This 2-step technique should carry you through potentially puzzling spirometry-E/M coding situations.

1. Don't Leave Out Signs and Symptoms On Your Claim

First on your to-do list is to report the patient's signs and symptoms. In this case, you would code 780.6 (Fever and other physiologic disturbances of temperature regulation), 786.05 (Shortness of breath), 786.50 (Unspecified chest pain), 783.21 (Loss of weight), and 780.79 (Other malaise and fatigue). Because these signs and symptoms resemble other respiratory problems, the physician performs a level four E/M and orders some diagnostic tests. Report the procedures with:

• 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) for the bronchoscopy with fluoroscopic guidance. Your physician is likely to perform this on a separate date.
• 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for the pulmonary function test (PFT); and
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity...) for the E/M. Some payers may require modifier 25 when an E/M is provided on the same day as PFTs.

Don't forget to assign 780.6, 786.05, 786.50, 783.21, and/or 780.79 to the E/M (99214) and diagnostic tests (31622, 94010) to show specific condition(s) that prompted each study. The primary diagnosis may vary for each service.

Profit: After performing and reporting each of the above tests and E/M could get you about $450 in revenue (9.24 RVUs for 31622 + 1.04 RVUs for 94010 + 3.01 RVUs for 99214 each multiplied by the 2011 conversion factor of 33.9764).

2. Reporting Spirometry Comes With A 'Baggage'

The PFT (94010) includes, is a component of, or mutually exclusive with the following tests when the physician performs them on the same day as per Correct Coding Initiative (CCI) edits:

• oxygen saturation assessment (94760, 94761)
• prolonged postexposure evaluation (94070)
• antigen challenge tests (95071)
• 94200, 94375
• 94012, 94014-94015
• 94060
• 94620-94621
• G0237-G0239, G0424

Reminder: To get paid for billing the codes separately when possible and appropriate, you have to use modifier 59 (Distinct procedural service).

Caveat: Watch out for the existing CCI bundle on 94010 with 94070 (Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents [e.g., antigen[s], cold air, methacholine]). When the pulmonologist physician performs spirometry (94010) first, the procedure indicates a problem that requires additional testing through the prolonged postexposure test (94070). Remember, you can only report these codes separately when they are done for separate and distinct reasons. In this case, you should append modifier 59 (Distinct procedural service) to 94010 to unbundle the edit.