Case Study, Part I:
Avoid Common Coding Snafus For Multiple Bronchoscopies
Published on Wed Jun 08, 2005
Use -25 if your physician provides other services with 99255 Pulmonologists frequently perform more than one procedure during a surgical session, so if you're not reporting each service properly, you could be receiving partial pay when you should receive well-deserved full reimbursement.
Following is Part I of a three-part series to help walk you through the many different aspects of reporting a complicated bronchoscopy case.
Note: The following operative note was reviewed by Denae M. Merrill, CPC, a pulmonology coder in Saginaw, Mich. Case Example: Patient Profile A physician admitted this 41-year-old patient to the hospital with a history of multiple medical problems.
The patient underwent cardiac catheterization, and the physician found that the patient had triple-vessel disease and recommended coronary artery bypass surgery. The patient underwent coronary artery bypass surgery.
The surgery went very well, but the patient was having difficulty ventilating in the recovery room. Therefore, the physician called in a pulmonologist for an urgent status consult. The pulmonologist was unable to obtain a complete history (including, HPI, ROS, and PFSH) because the patient was sedated. Past History The patient has a history of hypertension, diabetes, congestive heart failure, Charcot-Marie-Tooth disease, nephritic syndrome, and obesity.
Physical Exam The patient is morbidly obese. When the pulmonologist saw the patient, he was not in distress. He was well sedated and on a ventilator. His vital signs showed a temperature of 100, pulse 103, respiratory rate 17, blood pressure 117/49, CPAP 11, pulmonary artery wedge pressure 15, pulse oximetry was going down into around the mid-80s, and now after adjustment of the endotracheal tube, pulse oximetry has gone up to 92 percent.
The chest exam showed diminished breath sounds on the left and somewhat diminished sounds on the right side. The pulmonologist notes that the breath sounds were more diminished on the left side than the right side. The pulmonologist also noted a few rales and diminished air movement on the left side.
The patient's Doppler was negative for deep venous thrombosis (DVT). The pulmonologist reviewed the chest x-ray and showed significant volume loss on the left side and questionable congestion on the right side.
It was difficult for the pulmonologist to identify an endotracheal tube position on the repeat x-ray. The most recent labs showed sodium 140, potassium 4.6, chloride 105, bicarb 24, BUN 56, creatinine 6.5, glucose 101, white cell count 13.0, hemoglobin 9.5, platelets 156. His last set of arterial blood gases (ABGs) showed a ph of 7.33, pCO2 of 41, p02 of 76, bicarb of 31, and saturation 95 percent. Assessment Acute hypoxemia post-coronary artery bypass surgery likely related to either mucus plug or malpositioning of the endotracheal tube. Plan The anesthesiologist had a difficult time finding the carina during a bronchoscopy. [...]
