Pulmonology Coding Alert

Immunotherapy code Q2043 does not concern pulmonologists, and should remain an oncology issue.

The latest Correct Coding Initiative (CCI) edits bundle chest radiologic guidance with several procedures on the lungs and pleura, and although CCI edits 17.3 group immunotherapy code Q2043 with a number of ventilation and gas procedures, you shouldn't worry -- here's why.

Note: CCI edits 17.3 went into effect Oct. 1 and add 1,380 new edit pairs, according to Frank Cohen, principal and senior analyst for The Frank Cohen Group, LLC, in his NCCI 17.3 Update (available at www.frankcohen.com/html/access.html).

Prove Chest X-ray Distinctness From Thoracentesis To Override Bundle

For the latest CCI edits version, you should keep an eye on bundled chest x-rays and chest tube procedures. In particular, both 71010 (Radiologic examination, chest; single view, frontal) and 71020 (Radiologic examination, chest, 2 views, frontal and lateral) become components of:

• 32422 -- Thoracentesis with insertion of tube, includes water seal (e.g., for pneumothorax), when performed (separate procedure)
• 32550 -- Insertion of indwelling tunneled pleural catheter with cuff
• 32551 -- Tube thoracostomy, includes water seal (e.g., for abscess, hemothorax, empyema), when performed (separate procedure)
• 93503 -- Insertion and placement of flow directed catheter (e.g., Swan-Ganz) for monitoring purposes.

CCI edits cite the reason for the bundle as "misuse of column two code with column one code." These edits have a modifier indicator of "1", so you may override the edits with a modifier (i.e., modifier 59, Distinct procedural service) on the column 2 code when the services are distinct.

Example: A patient with COPD (490-496) gets admitted with shortness of breath (786.05) and chest pain (786.5), worsening with inspiration. A chest x-ray (71010) confirms pneumothorax (512.x) and the patient must undergo thoracentesis with insertion of tube (32422) to remove the excess air and allow for lung re-expansion. In this case, you would report 32422, 71010-59 to indicate that the chest x-ray was distinct from the thoracentesis.

Take note: Pulmonary specific guidelines govern the aforementioned Column 1 codes. For instance when coding 32422, you should consider a different radiologic guidance code for catheter placement/confirmation (e.g., 76942, 77002, 77012), which more accurately reflects the service description, method and service time associated with the procedural guidance provided, advises Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

The same guidelines apply for 32550-32551. In other words, you should consider code 75989 (Radiological guidance [i.e., fluoroscopy, ultrasound, or computed tomography], for percutaneous drainage [e.g., abscess, specimen collection], with placement of catheter, radiological supervision and interpretation) to represent radiologic guidance for catheter placement/confirmation, adds Pohlig.

She also warns that "you should use 71010 and 71020 only for radiologic examination of the chest, and not to assist or confirm needle placement."

Relax On Q2043 Bundle With Ventilation, Gas Procedures

Meanwhile, the Provenge code Q2043 (Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion) takes in the following ventilation and expired gas procedures as components:

• 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 -- ...including CO2 output, percentage oxygen extracted
• 94690 -- ...indirect (separate procedure)
• 94770 -- Carbon dioxide, expired gas determination by infrared analyzer.

As much as the Column 2 codes classify as pulmonology procedures, the grouping with Q2043 does not affect pulmonologists since it involves testing/monitoring being bundled into Provenge administration -- a treatment used for prostate cancer, explains Pohlig.