Pulmonology Coding Alert

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. Then the pulmonologist tried a bronchoscopy with a small bronchoscope. Once again, the pulmonologist could not see the carina and he also noted that it was difficult to go through the center of the endotracheal tube because there was hardly any space there.

The pulmonologist pulled out the tube by a couple of centimeters. He then pushed the bronchoscopy tube between the tracheal wall and the end of the tracheal tube.
  
At that time, the patient's oxygen improved. Finally, the pulmonologist noted a mucus plug that was almost completely occluding the left main bronchus and it was sitting on the carina, which made it nearly impossible to see the carina and the left main bronchus.

The pulmonologist went deeper down the main right bronchus, but once again, because of a small mucus plug, the pulmonologist could not visualize the subsegments.

Results

The pulmonologist's diagnosis included complete left lung collapse from a large mucus plug and also some kinking of the endotracheal tube against the tracheal wall.  After the pulmonologist adjusted the endotracheal tube and removed part of the mucus plug, the patient's oxygen improved to 92 percent.

Plan

At this time, the pulmonologist is waiting for a larger bronchoscope, which he will use to suction out the mucus plug completely.

Coding Solution

The documentation notes that the pulmonologist performed an urgent inpatient consultation. Therefore, you should report 99255 (Initial inpatient consultation for a new or established patient ...), considering the complexity of the case, the amount of data the pulmonologist reviewed and the level of high-complexity decision-making, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy and Critical Care at Emory University School of Medicine in Atlanta. 
 
In addition to high-complexity decision-making, the pulmonologist also needs to obtain and document a comprehensive history and exam. Without any of these criteria, you cannot report 99255.

Don't forget: You should also append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99255 because the pulmonologist provided the consult in addition to the bronchoscopy, Plummer says. 

The pulmonologist performed a diagnostic bronchoscopy, for which you should report 31622 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]). Therefore, your coding report should include code 99255-25 and code 31622. 

Extra: If the pulmonologist performs a second bronchoscopy to remove the mucus plugging, you should report a therapeutic bronchoscopy (31645, Bronchoscopy [rigid or flexible]; with therapeutic aspiration of tracheobronchial tree, initial [e.g., drainage of lung abscess]), says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. 

If he performed the second bronchoscopy on the same day, you should add modifier -59 (Distinct procedural service) to notify the payer that the pulmonologist performed a distinct service separate from the diagnostic bronchoscopy, Pohlig says. 
 
Don't forget: You should also report diagnostic code 518.81 (Acute respiratory failure) for the initial respiratory failure the patient suffered.
 
Also report 518.0 (Atelectasis) and 414.0x (Atherosclerotic heart disease) for the other conditions contributing to the patient's current physical condition.
 
Note: Please tune in next month to Pulmonology Coding Alert to read the next phase of this patient's course of treatment and the corresponding coding solution.