Pulmonology Coding Alert

Hint: Mind the NCCI edits.

If you’re monitoring patients with cystic fibrosis, chances are that your visits combine both E/M services and testing, which can require knowledge of bundling issues and NCCI edits. To get a handle on how to effectively bill for this condition, we’ve got a quick primer that will ensure you’re reporting these services correctly in 2019.

Pulmonologists order and perform services such as spirometry, chest x-rays and sputum testing to determine the CF patient’s condition throughout the course of the disease. In addition, they provide counseling and coordination of care to address any pulmonary problems caused by the condition.

The pulmonologist’s goal when treating CF is to slow lung damage, improve breathing by loosening and thinning mucus, and prevent or reduce lung infections. Typically, your practice employs five main methods in monitoring this condition:

1. Medications such as antibiotics to help control and prevent lung infections 

2. Bronchodilators to help open airway diameters in the bronchial tree 

3. Inhaled hypertonic saline and mucolytics to help thin mucus 

4. Airway clearance techniques, such as chest physical therapy 94667,  Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation; 94668, …subsequent), exercise and a variety of medical devices, to remove mucus from the lungs 

5. Bronchial alveolar lavage (31624, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage) to help clear away excess mucus.

How to Report Monitoring With Spirometry

Pulmonary physicians often use spirometry to monitor the lung function of their CF patients. You should use 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) to indicate repeat spirometries performed to evaluate a patient’s response to newly established treatments, to monitor the course of CF, or to evaluate a patient continuing with symptoms after initiating treatment. If the pulmonologist performs the spirometry both before and after administering bronchodilators, you should report 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration), which includes all of the work of 94010 plus more, and gives a better analysis of the problem and the effects of treatment.

You’ll also encounter a variety of additional codes, but many are considered bundled into 94060 by the National Correct Coding Initiative (NCCI) including 94200 (Maximum breathing capacity, maximal voluntary ventilation), 94375 (Respiratory flow volume loop), 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device), and 94770 (Carbon dioxide, expired gas determination by infrared analyzer). These component codes cannot be reported on the same date in addition to 94060.  

Keep in mind that 94200, 94640 and 94770 have a modifier indicator of “1” in the National Correct Coding Initiative. Therefore, they could be reported separately if performed as a separate and distinct procedure and not part of the same testing. To show this, you should append a modifier such as 59 (Distinct procedural service) to the bundled code.

Place of Service Key When Reporting Chest X-Rays

The chest x-ray is another important tool for pulmonologists monitoring CF patients’ conditions because it allows the physician to detect subtle changes in the lungs. But how to code the service depends on where the x-ray is taken.

If the pulmonary physician owns the x-ray equipment, he or she can bill for the x-ray (71045-71048). Frequently, however, the doctor sends the patient to an outside facility, which takes the x-rays and sends the films and a report back to the pulmonologist. In this case, the pulmonologist should factor his or her review of the x-ray(s) into the medical decision-making portion of the E/M service (99201-99215) provided to the patient.

If the pulmonologist sends the patient to an outside facility but interprets the x-ray(s) and generates the report, he or she should bill the appropriate x-ray code appended with modifier 26 (Professional component). In this instance, the pulmonologist would have to be the only one interpreting the films. The pulmonary physician could not do this in addition to the radiologist’s interpretation and charge for the service. Therefore, if the x-ray data comes to your practice with an interpretation and report already provided, you cannot bill for another one, since the radiologist has already billed for that service.

Know the ICD-10 Codes

When your pulmonologist confirms a CF diagnosis, you should think of the ICD-10 code family E84.0-E84.9. Although the code E84 (Cystic fibrosis) covers the general condition, you should consider going deeper into the family of codes to find a specific code. For example, if the patient has cystic fibrosis along with distal intestinal obstruction syndrome, you’ll report E84.19 (Cystic fibrosis with other intestinal manifestations).