Pulmonology Coding Alert

A patient with signs and symptoms of sarcoidosis presents numerous coding challenges to the pulmonologist. The physician must select the appropriate E/M level to reflect the large amount of work and complex decision-making normally involved in diagnosing these patients and in counseling them and monitoring effects of cortico-steroid therapy as part of follow-up. The coder must also use the correct ICD-9 codes to support medical necessity of office visits and diagnostic bronchoscopy before the patient is diagnosed with sarcoidosis.

Sarcoidosis is a multisystem disorder with an unknown etiology that produces an inflammatory response causing granulomas in the lungs and other organs. Patients suspected of having this condition are often referred to a pulmonologist by their primary care physician (PCP) who suspects the disease is the cause of symptoms ranging from fatigue (780.79) to shortness of breath (786.05). Or a specialist, such as a dermatologist, may refer the confirmed sarcoidosis patient for evaluation of possible pulmonary involvement.

"Sarcoidosis can resemble many other diseases," says Antoinette M. Revel, RN, NP, CPC, principal at Healthcare Consulting Services in Warrington, Pa. "It is often diagnosed where people present with complaints of arthritis (716.9x or 719.4x) or as the result of a routine chest x-ray that demonstrates mediastinal lymphadenopathy" (785.6). Pulmonologists could also code the chest x-ray findings as "abnormal x-ray findings of the lung" (793.1). Initial Consultative Visit A 62-year-old male Medicare beneficiary presents to a pulmonary physician with complaints of fatigue (780.79) and eye pain (379.91). He also has had an intermittent fever (780.6) since 1998. The patient describes arthralgias (719.49) that migrate, affecting his knees, ankles and elbows. Ankle involvement is universally present with sarcoid arthritis. He admits to some pleuritic pain (786.52) and shortness of breath. He takes Ultram for pain relief on an as needed basis, with minimal relief.

The patient is allergic to penicillin, has a medical history of liver disease (V12.70), smoked during his teens, worked in a paper mill and has a personal history of exposure to asbestos (V15.84). He recently retired from his job at a nuclear power plant. His father died of prostate cancer (V16.42).

The review of systems is positive for fatigue, eye irritation, sinus congestion, occasional abdominal pain and diarrhea. The comprehensive physical exam reveals an elderly male with axillary adenopathy, a facial rash, and a healing scar related to a recent muscle biopsy by the PCP to diagnose muscle pain and fatigue. All other systems are negative. The muscle biopsy report shows an inflammatory myositis (729.1). The chest x-ray obtained by the PCP two weeks earlier is clear with no infiltrates per the report. A computed tomography (CT) scan of the chest, obtained a month ago and reviewed that day by the [...]