Pulmonology Coding Alert

Focus: Bundles affect pulmonary function tests with coronary procedures.

If you’re thinking of reporting same session E/M services with any bronchoscopy or thoracoscopic procedures, don’t forget to check for Correct Coding Initiative (CCI) edits as the latest version 19.2 that became effective July 1, 2013 introduced an array of bundles that prevent you from reporting these services together.

Mammoth: In CCI version 19.2 “the number approaches 300,000, so this one is a whopper,” according to Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. “For column 2 codes, E/M led the pack with almost 95% of the total, so we can expect the changes in this release to affect everyone.”

Check Modifier Indicator to Unbundle Codes

CCI 19.2 ropes in almost every pulmonology procedural code that you normally use and bundles it with E/M services. Column 1 endoscopic procedures of the trachea and bronchi codes (31615-31651); thoracentesis and pleural drainage codes (32554-32557); thoracoscopy codes (32601-32673); tracheostomy procedure codes (31600-31614) and laryngoscopy procedure codes (31505-31579) bundle all of the following column 2 codes:

• Office/outpatient and inpatient problem-oriented E/M codes (99211-99239)
• Consultation codes (99241-99255)
• Critical care codes (99291-99292)
• Nursing care codes (99304-99316)
• Domiciliary, rest home, or custodial (assisted living) care codes (99324-99337)
• Care plan oversight code (99374-99378)

Global background:  Minor procedures (those with 0- and 10-day global periods) include an E/M service that was not “significant and separately identifiable” on the day of the procedure. Major procedures (with a 90-day global period) include any E/M services provided the day of and the day before the procedure.

“The inclusion of the E/M services have always been by definition part of the global period,” says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “Now it seems that CCI wishes to include these included E/M services by virtue of bundles in addition to the global definitions.”

In general when a patient has an out-patient endoscopic procedure at a hospital out-patient department or ambulatory surgery center, the regulation requires some documentation of a pre-procedure history & physician assessing the patient’s medical condition to safely undergo the procedure and receive medications for sedation.  The pre-procedure evaluation on the date of the procedure is included in the work defined for each procedure and is not considered a separately identifiable service.

Rationale: “CCI is now formalizing what was otherwise accepted as common practice amongst coders and payers,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia.  “Physician practices would often receive denials for the E/M services or requests for additional information supportive of the separate E/M when reported on the same day as any other procedure or service.” 

Reminder: The modifier indicator for all of these edits is “1,” which means you can override the bundling edits with the proper modifier in certain clinical scenarios. While the first modifier you’ll think of when talking about CCI edits is modifier 59 (Distinct procedural service), the modifiers most often used to override edits with E/M services will be modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

The standard pre-procedure H&P would not constitute a significant and separate service.  “Be sure to select the E/M modifier that best corresponds to the procedure and its global period,” advises Pohlig.  “An E/M performed on the same day as a 0- or 10-day global procedure will require modifier 25 when appropriate.  An E/M performed on the same day as a 90-day global procedure will require modifier 57, but only if the decision for surgery was made during that encounter.” 

Don’t Report PFT Codes With Atherectomy Services

As indicated in CCI 19.2, when your physician performs any services such as placement of an implantable subcutaneous defibrillator system or the insertion of a subcutaneous defibrillator electrode (0319T-0325T), you cannot report any ventilation management services or any other pulmonary function testing that is performed concurrently to assess the patient’s lung condition.

Similarly, the placement of an intracoronary stent or any other coronary atherectomy procedures that you report with the Outpatient PPS codes C9600-C9608 includes any ventilation or pulmonary function testing and codes for these services cannot be reported separately.

So, you cannot report these column 2 codes when your physician performs a service that you would report with the code ranges 0319T-0325T; or C9600-C9608:

• 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day)
• 94200 (Maximum breathing capacity, maximal voluntary ventilation)
• 94250 (Expired gas collection, quantitative, single procedure [separate procedure])
• 94680 (Oxygen uptake, expired gas analysis; rest and exercise, direct, simple)
• 94681 (Oxygen uptake, expired gas analysis; including CO2 output, percentage oxygen extracted)
• 94690 (Oxygen uptake, expired gas analysis; rest, indirect [separate procedure])
• 94770 (Carbon dioxide, expired gas determination by infrared analyzer)

Coding tip: The modifier indicator for all of these edits is “1” which means you can override the bundling edits with the proper modifier in certain clinical scenarios. You can use a modifier such as 59 to the column 2 codes to unbundle these codes and allowing you to report them as two separate services. However, you will need to provide adequate documentation supporting your claim to show how these services were separate and can be claimable.