Pulmonology Coding Alert

Don't let the absence of correlating symptoms keep you from reporting nonpulmonary tests performed on emphysema patients, since there are ways to receive reimbursement for these procedures that carriers often call screening tests.

Emphysema is a chronic lung condition that can potentially affect other organs or systems, including the heart. Consequently, routine office visits often involve more than simply monitoring the progression of the emphysema. The pulmonologist may find it necessary to check various functions of the heart.

Coders are often confused as to whether to report emphysema or a "screening" V code for these tests. "You should not use V codes if the patient has emphysema," says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. You should report emphysema as the ICD-9 code because this is the indication for the procedure.

"Screening" is not the operative word when referring to such procedures performed on emphysema patients, and the use of this word often confuses coders and leads to reimbursement problems. The crux of the difference between surveillance tests and preventive tests is the intent behind the test. Giving an emphysema patient an EKG is different from giving an EKG to a patient not suffering from the disease, although there are no clinical symptoms suggesting a heart problem in either scenario. Unlike performing an EKG for an insurance policy or employment physical, the procedure is medically indicated for the emphysema patient because of the patient's pulmonary disease, Pohlig says.

For an emphysema patient, the EKG is not seen as preventive, but necessitated, because the patient's condition may progress with cardiopulmonary complications. The EKG will reveal symptoms before physical symptoms manifest resulting in a more efficient treatment. When this test is used for surveillance measures, as opposed to a preventive one in the absence of any symptoms or conditions, you should code the test using the symptoms or illness warranting the test, such as emphysema.

For example, a 60-year-old man with emphysema who receives an EKG during a regular office visit would fall into this category. You would code the EKG with 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). If you report a code such as V81.2 (Special screening for cardiovascular, respiratory, and genitourinary diseases; other and unspecified cardiovascular conditions), which indicates that it was a screening service, then you will probably not receive reimbursement because most carriers will not pay for screening services. In this case, when it is a noncovered service, you will need to seek reimbursement from the patient. You do not need to have the patient sign an ABN to receive reimbursement from him.

But if you report the appropriate emphysema diagnosis code (492.x) with the EKG code, it may be considered "medically unnecessary." Remember that when you use an ICD-9 code that is not listed as covered for the EKG in the carrier's LMRP, it will more than likely be denied for reasons of medical necessity. In this case, you should have the patient sign an ABN prior to the service and attempt to receive reimbursement by this route of billing the patient for the medically "unnecessary" service if the service is denied.