Pulmonology Coding Alert

Uncover which of the 150 NMEs won't unbundle with any modifier.

If you commonly report pulmonary rehab code G0424, then you need to pay attention to the Correct Coding Initiative (CCI) edits version 16.3, which took effect October 1. Three of the 33 new mutually exclusive pairs concern pulmonologists, while non-mutually exclusive edits include 150 bundles representing pulmonary rehab.

In general, CCI 16.3 features 19,667 additions (33 mutually exclusive edits; 19,634 NMEs), and 31 deletions.

Highlight These Mutually Exclusive Pulmonary Rehab Pairs

Only 3 mutually exclusive edits should affect pulmonologists in this latest version. Mutually exclusive edits mean the code pair "represents procedures or services that could not reasonably be performed at the same session by the same provider on the same beneficiary," according to CMS. Medicare will only reimburse you for the lesser-valued of the two procedures.

The new comprehensive pulmonary rehab (PR) code G0424 (Pulmonary rehabilitation, including exercise and monitoring, per hour, per session) is mutually exclusive with thethree older PR codes:

• G0237 -- Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minutes [includes monitoring]
• G0238 -- Therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, per 15 minutes [includes monitoring]
• G0239 -- Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals [includes monitoring].

"Pulmonary rehab services are mutually exclusive of respiratory therapy services that can be included as part of the pulmonary rehab session," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

Note: CCI assigns a modifier indicator of "0" to all of these edit pairs, which means you cannot override the edit by reporting the appropriate modifier (such as modifier 59, Distinct procedural service). In short, you cannot report the procedures together under any circumstances.

Find Out What Modifier Indicator "1" Means

Additionally, CCI 16.3 categorizes G0424 as a comprehensive non-mutually exclusive bundle of the following component codes in physical medicine and rehabilitation:

Laboratory procedures and interpretation of test results, such as 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation), 94200 (Maximum breathing capacity, maximal voluntary ventilation), and 94680 (Oxygen uptake, expired gas analysis; rest and exercise, direct, simple) Physical/occupational therapy (re)evaluation, such as 97001-97004 Therapeutic procedures, such as 97110 (Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility), 97150 (Therapeutic procedure[s], group [2 or more individuals]), and 97530 (Therapeutic activities, direct [one-to-one] patient contact by the provider [use of dynamic activities to improve functional performance], each 15 minutes) Tests and measurements, such as 97750 (Physical performance test or  measurement [e.g., musculoskeletal, functional capacity], with written report, each 15 minutes).

Also, medical nutrition therapy codes (97802-97804) are a component of the procedure G0424. "Pulmonary rehab includes physician-prescribed exercise, education and training, psychosocial assessment, outcome assessment, and all monitoring performed on the same day," Pohlig sums up.

Remember: Non-mutually exclusive edits pair codes for two services that physicians often perform during the same session. CCI lists one code as the comprehensive procedure -- meaning it's considered the larger procedure -- and the second code as the component, which is a piece of the comprehensive. All non-mutually exclusive edits for pulmonology carry a "1" indicator -- except94667 (Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation), 94668 (...subsequent), and 94770 (Carbon dioxide, expired gas determination by infrared analyzer), which carry an indicator of "0".

Bundles with a "1" indicator means you can report both procedures of a pair in certain, although unlikely, circumstances. These circumstances include performing the procedures at separate sessions on the same day.