Pulmonology Coding Alert

Tuberculosis (TB) is a growing health threat nationwide and a problem seen by pulmonary physicians with increasing frequency. The patient who presents with a cough (786.2), weight loss (783.21) and intermittent fever (780.6) must be evaluated carefully to rule out TB along with any number of other conditions, including malignancy and HIV. TB is, however, a common co-infection seen in people who have HIV.
 
The following case study highlights some of the challenges practices will encounter in diagnosing and coding for the patient with TB.
Initial Referral
A primary care physician (PCP) refers a 66-year-old man with Medicare Part A and B coverage to the pulmonologist for evaluation of a chronic cough and an unintended 10-pound weight loss. The patient appears unwell: pale, with a resting respiratory rate of 28. His last purified protein derivative (PPD) skin test for TB at the public health clinic was negative.
 
On the first consultative visit (99241-99245), the pulmonologist reviews the patient's lengthy medical records and most recent chest x-ray, which shows a fibronodular infiltrate in the right upper lung. Next, an extensive history and physical are performed. The patient admits to multiple sexual encounters, but denies intravenous drug use. The pulmonologist orders a complete blood count, which the hospital lab used by the pulmonology practice reports as showing a slight iron-deficiency anemia (280.9) and a mild leukocytosis (288.8).
 
The nurse administers a repeat skin PPD and performs venipuncture to obtain blood samples for histoplasmosis and HIV, which are sent to a regional clinical pathology lab. The patient is rescheduled for a follow-up visit in one week to review the test results and undergo a more extensive diagnostic workup. The patient is referred to the radiology clinic for a repeat chest x-ray after the visit.
Billing the Initial Consultation
The initial consult is billed using E/M codes for consultation (99241-99245), which includes the three key components history, exam and medical decision-making. The pulmonologist chooses to code 99245 due to the comprehensive history and exam, the lengthy medical-record documentation that he reviewed, and the complexity of the diagnostic workup required to confirm the diagnosis.
 
The pulmonologist documents in the progress notes that he or she "reviewed the report" and/or "personally viewed the films." The histoplasmosis and HIV would be billed to Medicare by the lab analyzing the specimen, which submits the CPT code to Medicare and is paid under the Laboratory Fee Schedule, not the Physician Fee Schedule. However, the pulmonologist should provide the appropriate diagnosis coding with the lab order (either the reason for the test or the visit) so the lab can get paid. In this case, the ICD-9 codes supporting medical necessity of the lab tests are cough (786.2), weight loss (783.21) and [...]