Pulmonology Coding Alert

CCI also focuses on completing the list of ME pairings for polysomnography.

While you’re working to integrate the CPT® 2014 interprofessional consultation codes and fresh guidelines for TCM into your coding, don’t overlook the most recent Correct Coding Initiative (CCI) edits (20.0) which govern how you’ll report these codes with other procedures.

Pay Attention to Patient Age While Reporting Polysomnography

When reporting polysomnography, one of the parameters that you will use to choose the appropriate code for the procedure will be to check the age of the patient. So, depending on the age of the patient, you have two sets of codes for reporting polysomnography (one for age below six and the other for patient aged above six).

According to CCI 20.0, these two code sets based on the age are bundled as “mutually exclusive procedure” pairs. So, according to this set of edits, you cannot report 95782 (Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist) with 95810 (Polysomnography; age 6 years or older,…) or 95783 (Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist) with 95811 (Polysomnography; age 6 years or older,…) as these codes are mutually exclusive based on age and cannot be reported for the same patient.

Reminder: The CPT® codes 95782 and 95783 are listed as column 1 codes for the mutually exclusive pairing with 95810 and 95811 respectively. These edits carry the modifier indicator ‘0,’ which means that you cannot unbundle the edits by using a modifier.

Watch For Edits Pairing PFTs With E/M Codes

If you’re reporting pulmonary function tests (PFTs) with evaluation and management (E/M) codes, CCI 20.0 has introduced edits bundling these codes together. These edits include PFTs reported with the code range 94010-94799 in column one and the following E/M service code ranges as column two codes:

• Office/outpatient and inpatient problem-oriented E/M codes (99211-99239)
• Consultation codes (99241-99255)
• New or established patient emergency department codes (99281-99285)
• Nursing care codes (99304-99316)
• Domiciliary, rest home, or custodial (assisted living) care codes (99324-99337)
• New or established patient home services (99341-99350)

Background: E/M services have always been considered part of a procedure by virtue of the rules defining global periods. Minor procedures (those with 0- and 10-day global periods) may include a minor E/M service that was not “significant and separately identifiable.” Major procedures (with a 90-day global period) have always included any E/M services provided the day of and the day before the procedure, and those provided 90 days afterwards, unless separately identifiable issues were addressed.

The modifier indicator for most of these edits is “1.” That means you can override the bundling edits with the proper modifier in certain clinical scenarios. The modifiers that you will have to use to break these particular 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 modifier will have to be appended to the E/M service code as these are the codes listed in column two of the edits, but only when appropriate.

Caveat: Some edits do carry the modifier indicator ‘0,’ meaning you cannot override the edits by using a modifier. So, don’t blindly rush into appending the modifier 25 to the E/M code. When reporting a PFT code with an E/M service that is significant and separately identifiable, check the modifier indicator to see if the edits can be overridden. If the modifier indicator is ‘0,’ report only the PFT code.

Don’t Report Interprofessional Consultation Codes With Procedural Codes

While 2014 saw the introduction of four time based codes (99446-99449) to report the work of two medical professionals who discuss a patient’s condition via phone or internet, CCI 20.0 brought in several edits that do not allow you to report these codes with procedural codes.

While speculation was rife about whether or not these codes would be separately payable from other services provided to a patient on the same date, the edit pairings have laid to rest these thoughts and made it clear that the answer is “No,” in most cases.“With relatively few exceptions, the modifier indicator associated with these edit pairs is ‘0,’ so you will not be able to override the edit with a modifier,” observes Kent Moore, Senior Strategist for Physician Payment at the American Academy of Family Physicians. “Since the interprofessional consultation code is the Column 2 code in each case, it will be the code that is denied in favor of the procedural code reported on the same date,” adds Moore.

So, if you are planning on reporting these codes with any other procedural codes, you’ll have to check CCI edits to see if these codes are paired.

Reminder: CCI 20.0 also pairs these codes as Column 2 codes with E/M service codes. So, you cannot report these codes if you are reporting any other E/M service code for the same session also. Note that these pairings also carry the modifier indicator ‘0’ which means that you cannot undo these edits by using any modifiers.

Example: A gastroenterologist refers a patient whom he has been treating previously for gastroesophageal reflux disease (GERD) to consult with your pulmonologist for symptoms of wheezing and cough that he has been experiencing. The gastroenterologist is of the opinion that the pulmonary symptoms that the patient is currently experiencing is being caused as a complication of the GERD and needs your pulmonologist’s opinion.

Your pulmonologist reviews the patient’s history, assesses his signs and symptoms and subjects the patient to a physical examination and performs some diagnostic tests (bronchoscopy and pulmonary function tests). Based on history, the observations made during physical examination and bronchoscopy, and interpretation of the diagnostic tests your pulmonologist is able to confirm a diagnosis of asthma that is being caused as a complication of GERD.

Your pulmonologist then spends 20 minutes over the phone with the gastroenterologist discussing his observations and interpretations of tests. He also discusses treatment options to help relieve the pulmonary symptoms and how treating the GERD might influence the reduction of the asthma like symptoms.

Since you will be reporting an E/M code for the evaluation of the patient by your pulmonologist, you cannot report 99447 (Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review) to report the time spent by your clinician for discussion with the gastroenterologist as CCI 20.0 bundles these codes together. “Note that Medicare has excluded these services as covered services, so please check with the payers to determine if they are covered or left to the patient’s responsibility,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia.

Omit TCM Billing With Other Procedural Codes

As of Jan. 1, 2014, CCI bundles transitional care management (TCM) codes (99495-99496, Transitional Care Management Services with the following required elements: Communication [direct contact, telephone, electronic] with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit ...) into many procedural codes, including some that you will use in day-to-day pulmonology coding.

If you plan to report a surgical or medical procedure and a TCM code on the same date of service, you may face denial of the TCM code. A few of the TCM code edits have a modifier indicator of ‘1.’ However, most have a modifier of ‘0.’ “If you plan to report TCM and a procedural service on the same date of service, you would be well advised to check the CCI to see if an edit applies,” notes Moore. “If so, you also need to check whether or not a modifier is allowed with that particular edit,” adds Moore.