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Pulmonology Coding Alert

Code All Services When Treating Sarcoidosis Patients to Optimize Reimbursement

Published on Wed May 01, 2002

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 pulmonologist, shows no evidence of parenchymal disease. A blood chemistry panel obtained that day shows an elevated lactic dehydrogenase (LDH); a gallium scan report indicates increased sinus uptake consistent with sinusitis. A follow-up chest x-ray of the patient reveals abnormal findings on radiological examination, lung field (793.1).

The physician's impression is as follows:

  • Chronic fatigue (780.79)

  • Migratory arthralgias (719.49)

  • Chest tightness (786.59)

  • Shortness of breath (786.05)

  • Sinusitis (473.9)

  • Abnormal chest x-ray changes (793.1)

  • Rule out sarcoidosis.

    The pulmonologist's plan of care is as follows:

  • review the muscle biopsy slides
  • refer the patient for an ear, nose and throat evaluation for the sinusitis
  • perform a diagnostic bronchoscopy for suspected sarcoidosis related to the shortness of breath, chest tightness, fatigue and arthralgias.

    Coding,Documenting the Visit

    Because the pulmonologist performed a comprehensive history and exam and engaged in high-complexity decision-making, he or she could bill 99245 (Office consultation for a new or established patient, which requires a comprehensive history, comprehensive examination, and medical decision-making of high complexity), the highest-level consultation for a new patient. The key to billing this level of service is documenting the work performed by the physician, says Mary Mulholland, RN, BS, CPC, reimbursement analyst at the University of Pennsylvania department of medicine in Philadelphia. "The old adage, 'If it's not documented, it's not done,' still stands," she cautions.

    Thus, the documentation should include brief notations that the pulmonologist reviewed the CT films and the report of the chest x-ray, muscle biopsy and gallium scan, and evaluated the blood chemistry studies, etc. The medical record notation should also include all the elements of the history and physical, especially the significant family and social history. The pulmonologist should ensure that his or her thought processes regarding how the plan of care and differential diagnoses were developed (e.g., rendering medical decision-making of high complexity) would be clear to an auditor reviewing the record.

    To support a level five consultation for a new patient, the physician has to perform and document the following:

  • History of present illness: Four elements of the presenting problem.

  • Review of systems: Greater than or equal to 10 systems. The pulmonologist reviewed all bodily systems in obtaining a history.

  • Past family social history: Three histories. This patient had one item in each of these areas.

  • Exam areas/systems: Greater than or equal to eight (using the 1995 exam guidelines).

  • Medical decision-making: In this consultation, the level of medical decision-making is high, based on the number of diagnoses/treatment options, the amount of data reviewed/ordered, and the risk of complication, morbidity/mortality.

    For example, the pulmonologist performed an independent visualization of the CT scan of the chest and gallium scan, which is equal to 2 points (regardless of how many items visualized); reviewed the chest x-ray (1 point); and reviewed the medical tests (electrolytes), which is another point. All of this must be documented in the patient's medical record.

    Note: Reporting a "rule out" or suspected diagnosis is inappropriate, according to Revel. A sarcoidosis diagnosis usually is confirmed through tissue biopsy with microbiologic and histologic examination.

    Coding Bronchial Biopsies

    The pulmonologist schedules the patient for a bronchoscopy with mucosal biopsies (31625) and transbronchial biopsies (31628). According to CPT, the diagnostic bronchoscopy (31622) is bundled into the surgical bronchoscopies (31623-31656). Therefore, the pulmonologist could not bill 31622 on the same claim as 31625 and 31628. The physician should append modifier -59 (Distinct procedural service) to 31625.

    The procedure is billed using ICD-9 codes for the signs and symptoms that justify the medical necessity of the testing. In this case, these codes would be 793.1, 786.05 and 719.49. The pathology report is compatible with a diagnosis of sarcoidosis with lung involvement. Once this diagnosis is made by the pulmonologist based on the biopsy and signs and symptoms, the physician would use 135 (Sarcoidosis) and 517.8 (Lung involvement in other diseases classified elsewhere) for follow-up visits, advises Tammy Huard, RHIT, coding coordinator for MeritCare Health Systems in Fargo, N.D.

    Managing the Patient on Corticosteroids

    After the pathology report confirms sarcoidosis with pulmonary involvement, the patient sees the pulmonologist for a follow-up visit. The physician discusses with the patient the diagnosis and the risks and benefits of corticosteroid therapy, which is the only medical treatment for sarcoidosis. Methotrexate, however, can be used when steroids are not effective.

    The pulmonologist also explains that the disease frequently goes into remission, which makes it difficult to evaluate the effectiveness of the cortisone. The pulmonologist spends 50 minutes counseling the patient about the medication and its potential side effects. The patient discusses the potential side effects with his wife and decides to try a course of pulse dose corticosteroid therapy to see if it will improve his shortness of breath, muscle pain and chest tightness.

    Although the duration of an office visit normally does not dictate the level of services billed, in this case it would because the pulmonologist spent more than 50 percent of the visit counseling the patient. As long as the time and content of the counseling are documented, bill 99215 (Office or other outpatient visit for the evaluation and management of an established patient) solely based on the time spent by the pulmonologist. The threshold for billing a 99215 is 40 minutes.

    Use V Codes for High-risk Medication

    How would the corticosteroid therapy affect complexity of decision-making as part of follow up? "Since this is a high-risk medication, it makes decision-making more complex," says Teresa Thompson, CPC, CCC, principal at TM Consulting in Sequim, Wash. If the physician needs to monitor the patient for toxicity of the therapy, he or she should include this in the documentation because this increases the risk of complication, morbidity or mortality of the patient.

    In addition, the physician can use a V code to support the complexity of medical decision-making for future office visits. Use V58.69 (Long-term [current] use of other medications) when caring for the patient who is taking steroids or methotrexate.

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