Pulmonology Coding Alert

Many subscribers are unclear about the specifics of hospital coding for pulmonary care, specifically when critical care is involved. Careful attention to the insurers guidelines and Correct Coding Initiative (CCI) edits can help resolve many of these issues.

Coding Two Hospital Visits on the Same Day

A pulmonologist visits a patient with emphysema (ICD-9 492.8 ) who is in stable condition. The doctor examines the patients lung volume report, performs an expanded problem-focused exam and directs the respiratory therapist to adjust the ventilator settings. The pulmonologists visit meets the criteria of 99232 (subsequent hospital care, per day, for the evaluation and management of a patient), which he documents in the patients chart.

Later that day, the patient has a respiratory arrest (ICD-9 799.1 ), and the pulmonologist returns to the hospital to provide one hour of critical care services (99291, critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). Can the pulmonologist bill for the visit in the morning and the critical care in the afternoon?

Most of the time, we wouldnt bill two evaluation and management (E/M) codes on the same day for the same patient, says Shirley Pope, office manager at Asheville Pulmonary Associates in Asheville, N.C., but this is the one exception. If the pulmonologist makes rounds in the morning, then the patient crashes in the afternoon and he has to go back to treat the patient as critical care, you can bill for both E/M visits.

Section 15508(F) of the Medicare Carriers Manual states, If there is a hospital or office/outpatient evaluation and management service furnished early in the day and at that time the patient does not require critical care, but the patient requires critical care later in the day, both critical care and the evaluation and management service may be paid.

Billing for the morning E/M code and the afternoon critical care code requires modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Lori Patak, supervisor of the pulmonary department at United Medical Associates, a four-pulmonologist practice in Johnson City, N.Y. Respiratory arrest definitely would meet the criteria for a critical care service, she says. Therefore, report 99232 for the morning hospital care with modifier -25 and include the ICD-9 code for emphysema (492.8).

To avoid the risk of your insurer paying the critical care code but not the previous hospital visit code, you should send your claim via hard copy (rather than electronically). Attach chart notes to prove medical necessity for both visits showing that the patients care deteriorated later in the day.

In addition, your notes must indicate the amount of time that the pulmonologist spent performing critical care services because these codes are billed based on the face-to-face time with the patient. Bills submitted for 99291 and its add-on code, 99292 (critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes), should include the total duration of time spent with the patient even if the care provided by the physician on that date is not continuous.

Procedures Billed With Hospital Visits

What if the pulmonologist who provided critical care services to the respiratory arrest patient then performed an emergency endotracheal intubation (31500), arterial catheterization (36620) and initiated ventilator management (94656)? The physician would charge for the critical care, the endotracheal intubation and catheterization, but the critical care code (99291-99292) includes ventilator management, so he would not charge 94656, says Patak.

The critical care guidelines in CPT 2000 state that ventilator management services (94656-94662) are included in reporting critical care. If the physician in the previous example personally performed the ventilator management, however, he could include the total time spent for performing critical care services.

Note: Critical care services also include chest x-rays (71010, 71020), interpreting cardiac output measurements (93561, 93562), analyzing data stored in computers (99090), gastric intubation (91105), temporary transcutaneous pacing (92953) and vascular access procedures (36000, 36410, 36415, 36600). These services should not be reported separately when billing 99291 and 99292.

The catheterization and endotracheal intubation are not bundled as part of CCI, so modifier -59 (distinct procedural service) is not required to bill the codes together. Pulmonologists still must add modifier -25 to the critical care code to indicate that the other procedures were separately identifiable from 99291. Because 31500 and 36620 are reported separately, the pulmonologist cannot add the time spent performing these procedures as part of critical care time.

In some states, such as Alabama, the Medicare carrier requires that any claims for 31500, which is strictly for emergency endotracheal intubation, include documentation of medical necessity with the claim, including the history and physical, progress notes and operative record. In this case, you also should include information with the claim about the reason you were performing critical care services and the amount of time you spent. Most other Medicare and private insurers, however, would require the claim to include an applicable ICD-9 code supporting the emergency intubation. The respiratory arrest code would support the 31500 code for intubation.

Insurers rules for billing critical care services vary. Before submitting any claims with these codes, review your local policies.