Pulmonology Coding Alert

Chronic obstructive pulmonary disease (COPD) includes chronic bronchitis (491.9) and emphysema (492.8) characterized by irreversible airflow obstruction. As much as 10 percent of the population more than 65 years of age are estimated to have COPD, and the number of cases grows as the population ages.

Pulmonologists document COPD patient records with various patient-reported symptoms, tests, diagnoses and treatments, including the following.

Coding Spirometry

Spirometry (94010-94070) is the recommended test for COPD. Use 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) to indicate repeat spirometries performed to evaluate a patients response to newly established treatments, to monitor the course of COPD, or to evaluate a patient continuing with symptoms after initiation of treatment.

Proper documentation for this procedure should include:

The medical necessity of these tests, such as diagnosis codes, must be submitted on all claims.

All providers of pulmonary function tests should have on file a referral (a prescription) with clinical diagnoses and requested tests. Indications for the studies should be described clearly in the clinical records and available for review.

All equipment and studies should meet minimum standards outlined by the American Thoracic Society (see Standardization of Spirometry at www.thoracic.org/statementframe.html).

Spirometry studies, in particular, require a minimum of three attempts that must meet minimum acceptability criteria.

All studies require an interpretation with a written report. Computerized reports must have a physicians signature attesting to its accuracy.

Multiple Tests Means Multiple Codes

Pulmonologists often must perform multiple tests before making a definitive diagnosis if the patient presents with complex problems. For example, if a patient reports shortness of breath (786.05), wheezing (786.07) and breathlessness (786.09) after exertion, your pulmonologist could order the spirometry.

The test results are normal, but the patients condition remains unchanged. The cause of the patients complaint must still be determined, so the patient undergoes a simple pulmonary stress test (94620, pulmonary stress testing; simple [e.g., prolonged exercise test for bronchospasm with pre- and post-spirometry]). Because both tests are needed, your practice could bill for both the spirometry and the stress test by adding modifier -59 (distinct procedural service) to the 94620, according to Walter J. ODonohue, MD, FCCP, FACP, a representative to the AMA CPT Advisory Committee for the American College of Chest Physicians (ACCP) and CPT/RUC Committee chair of the ACCP.

Coding for Oxygen Treatments

In the April 1998 Postgraduate Medicine (Vol. 103, No. 4), John G. Weg, MD, and Carl F. Haas, MLS, RRT, of the department of internal medicine at the University of Michigan Medical School in Ann Arbor, write, The role of long-term oxygen therapy for hypoxemia in patients with chronic obstructive pulmonary disease is well established. Oxygen is an effective prescription drug for hypoxemic patients with chronic obstructive pulmonary disease (COPD).

Medicare coverage of home oxygen and oxygen equipment under the durable medical equipment (DME) benefit is considered reasonable and necessary only for patients with significant hypoxemia (799.0) who meet the medical documentation, laboratory evidence and certain health conditions specified in the Medicare Carriers Manual.

Complete form HCFA 484 (Certificate of Medical Necessity: Oxygen) to establish coverage criteria and ensure that the oxygen services provided are consistent with the physicians prescription or other medical documentation. The attending physician must review and sign the form before submission.

Claims for oxygen also must be supported by medical documentation in the patients record. Separate documentation is used with electronic billing. This documentation may be a prescription written by the attending physician and must specify:

A diagnosis of the disease requiring home use of oxygen;
The oxygen flow rate; and
An estimate of the frequency, duration of use (e.g., two liters per minute, 10 minutes per hour, 12 hours per day), and duration of need (e.g., six months or lifetime).

Note: A prescription for Oxygen PRN or Oxygen as needed does not meet this last requirement. Neither provides any basis for determining if the amount of oxygen is reasonable and necessary for the patient.

What Are NPPV and NPPRA?

Nasal positive pressure ventilation (NPPV) has been used increasingly over the last 10 years. Pulmonary physicians are now caring for more people at home using complex technology previously used almost exclusively in acute hospital and intensive care settings reports Edward A Oppenheimer, MD, FCCP, pulmonary medicine, in the October 2000 issue of the ACCPs California chapter newsletter.

Noninvasive positive pressure respiratory assistance (NPPRA) is the administration of positive air pressure, using a nasal or oral mask avoiding the use of more invasive airway access, such as a tracheotomy.

A respiratory assist device (RAD) without backup rate (K0532) delivers adjustable positive air pressure through a nasal or oral facial mask to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs. A RAD with backup rate (K0533) provides the same function and includes a timed backup feature to deliver the air pressure whenever sufficient spontaneous inhalation efforts fail to occur.

Patients covered for the first three months of a K0532 or K0533 device must be re-evaluated to establish the medical necessity of continued coverage. Although the patient may need to be evaluated at earlier intervals after this therapy is initiated, the re-evaluation upon which Medicare will base a decision to continue coverage beyond this time must occur within 61 to 90 days of initiating therapy by the treating physician.

RAD Coding Guidelines

1. HCPCS codes E0452, E0453 and K0194 are no longer valid for submission to the DMERC.

2. If a respiratory assist device is used to apply NPPRA therapy that does not have the timed backup feature, bill using K0532; if it has a timed backup feature, bill using K0533.

3. For devices previously coded as E0452 or E0453, code E0452 as K0532, and if the E0453 is being used with a noninvasive interface to administer NPPRA therapy, code as K0533.

4. For devices previously billed as K0194 (intermittent assist device with continuous positive airway pressure device [CPAP], with humidifier), use K0532 and K0268 (humidifier, nonheated, used with positive airway pressure device).