Pulmonology Coding Alert
Look to Tree for Medical Necessity Knowledge
Is patient eligible for Xolair? These questions will help you find out However, BlueCross BlueShield of Tennessee formulated a tool that will help you make the medical- necessity decision. To determine the eligibility status of patients who might receive Xolair, follow this Pharmaceutical Decision Support Tree: 1. Has the individual been diagnosed with an allergic condition, other than allergy-related asthma? If yes, this does not meet medical-necessity and/or medical-appropriateness criteria. If no, go to question #2. 2. Does the individual have a diagnosis of moderate to severe persistent allergic asthma? If yes, go to question #3. If no, this does not meet medical-necessity and/or medical-appropriateness criteria. 3. Is the individual 12 years of age or older? If yes, go to question #4. If no, this does not meet medical-necessity and/or medical-appropriateness criteria. 4. Did the individual test positive to at least one perennial aeroallergen by a skin test (for instance, prick/puncture test, intracutaneous test) or a blood test (such as RAST)? If yes, go to question #5. If no, this does not meet medical-necessity and/or medical-appropriateness criteria. 5. Is the individual's IgE level greater than or equal to 30 and less than or equal to 700 IU/mL? If yes, go to question #6. If no, this does not meet medical-necessity and/or medical-appropriateness criteria. 6. Is the individual currently using oral/inhaled corticosteroids at maximum doses? If yes, go to question #7. If no, this does not meet medical-necessity and/or medical-appropriateness criteria. 7. Is the individual's asthma inadequately controlled despite the regular use of inhaled corticosteroids at maximum doses? If yes, go to question #8. If no, this does not meet medical-necessity and/or medical-appropriateness criteria. 8. Is the individual being treated with a long-acting beta 2-agonist? If yes, this satisfies medical-necessity and medical- appropriateness criteria If no, this does not meet medical-necessity and/or medical-appropriateness criteria.
Pulmonology Coding Alert
- On the Cutting Edge:
Prove Patient's Asthmatic Status When Reporting Xolair
And don't forget to code for the supply, or you'll lose $$When the pulmonologist (or [...] - Coding Tool:
Look to Tree for Medical Necessity Knowledge
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'Nebulizer and Supply Bundles
Question: The pulmonologist's staff performs pressurized inhalation treatment with a nebulizer. May I report nebulizer [...] - Reader Questions:
V Code Vital for TB Test Claim
Question: When the pulmonologist's staff applies a purified protein derivative (PPD) tuberculosis (TB) test on [...] - Reader Questions:
If Encounter Is for Training Only, E/M Not Possible
Question: An established patient with acute bronchitis reports to the pulmonologist's office for a scheduled [...] - Reader Questions:
Loop-E/M Encounter Results in 2 Codes
Question: If the pulmonologist performs flow volume loop and an E/M service, is the loop [...] - Reader Questions:
Review Apnea Codes Before Making Choice
Question: The pulmonologist performs a level-three E/M on a new patient. Notes indicate that the [...] - Reader Questions:
Zoom In on 'Targets' Before Coding Sedation
Question: An established 64-year-old patient reports to the pulmonologist for a scheduled flexible bronch-oscopy. The [...] - Reader Questions:
You'll Code Differently for Blood Draws, Lab
Question: We saw a patient for a blood draw and sent it to an outside [...]
