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Pulmonology Coding Alert

Cold and Flu Season:

Dont Sweat It What To Do When a Cold Becomes Pneumonia

Published on Tue Jan 01, 2002

Pulmonologists often care for patients with chronic respiratory disease who develop pneumonia during the "cold and flu" season. In some situations, they must know how to code outpatient and inpatient evaluations and procedures provided on the same day to patients who become acutely ill with pneumonia-related complications.
 
Physicians may also be asked to provide a preoperative consultation to determine whether a patient who's had a recent bout of pneumonia and other respiratory risk factors can withstand surgery. To code these consults correctly requires an understanding of new CMS guidance for carriers, which went into effect Oct. 1, 2001, (transmittal 1719).
 
The following case example takes a pneumonia patient who develops empyema and atelectasis from the primary care setting through an outpatient pulmonology consultation, an inpatient stay, and a preoperative pulmonology consultation for an unrelated surgical problem.

Outpatient Treatment of Pneumonia

A 66-year-old male patient with a history of heavy smoking and chronic obstructive pulmonary disease (COPD) (496) presents to his primary care physician (PCP) with a slight fever (780.6) and productive cough (786.2). The PCP obtains a sputum for culture and sensitivity and performs a chest x-ray. The diagnosis is right lower lobe pneumonia (481). The PCP prescribes a 14-day course of quinolones and instructs the patient to return if his fever or other symptoms worsen.
 
The sputum culture reveals a nonspecified Gram-negative bacterial pneumonia (482.83). After five days, the patient returns to the PCP with a fever of 102 degrees,
a deep, productive cough with green, blood-flecked sputum (786.3, hemoptysis), shortness of breath (786.05) and right pleuritic chest pain (786.52). The patient is scheduled for evaluation midmorning by a pulmonologist in the same office complex.

Pulmonology Workup

The patient presents to the pulmonologist's office at 11 a.m. The physician conducts a history and physical exam and obtains a chest x-ray. He then performs a thoracentesis (32000) in the procedure room in his office, concluding that the patient may have parapneumonic empyema (510.9). By late afternoon, the lab calls back results confirming this diagnosis.
 
The pulmonologist consults with the PCP, who agrees the patient should be hospitalized immediately. The patient is admitted to the general medicine floor and started on IV antibiotics. That evening, the patient develops worsening shortness of breath, and an x-ray reveals a partially collapsed right lung (atelectasis). The pulmonologist inserts a chest tube (32020) in the patient's right pleural space to drain fluid, which eases breathing.

Coding Consults Versus Admissions

How the pulmonologist bills for all the prior services depends on who admits the patient to the hospital.
 
If the PCP admits the patient and the pulmonologist only performs the chest-tube insertion, the pulmonologist bills for the outpatient consultation earlier in the day (99241-99245), the thoracentesis (32000) and the chest-tube insertion (32020).
 
However, if the pulmonologist admits the patient, he cannot bill for the outpatient consultation on the same day as the admission. In this case, the pulmonologist would bill the admission service (99221-99223, inpatient) and the chest-tube insertion on an inpatient basis.
 
"Pulmonologists are generally paid more for a consult than an admission," says pulmonologist William Haik, MD, principal, DRG Review in Ft. Walton Beach, Fla., because "the highest-weighted consult provides more reimbursement than the highest-weighted admission to the hospital." Thus, where there's an option, the pulmonologist's decision to admit a patient or provide a consult should be made and documented as one that best ensures the quality and continuity of care for the patient.

ICD-9 Codes Must Support Medical Necessity

How should the pulmonologist code the myriad of diagnoses the patient has had in one day to support medical necessity of procedures and visits? "For the thoracentesis performed in the office, the pulmonologist would code the symptoms as medical necessity for the procedure (dyspnea, etc.) since the empyema cannot be confirmed at the time of the visit. The diagnosis of pneumonia can be reserved for the office visit," says Mary Mulholland, RN, BSN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia.
 
"The physician bills services daily based on the rank ordering of diagnoses or priority of what he or she treated for a particular encounter," she adds. "Therefore, the admitting doctor reports a diagnosis of empyema (510.9) but records a diagnosis of atelectasis (518.0) for insertion of the chest tube."

Preoperative Consult on the Same Patient

The patient returns home after a seven-day hospitalization on oral antibiotics with instructions to see the pulmonologist for a follow-up evaluation within two weeks. Before that visit, however, the patient presents to the emergency room with signs and symptoms of acute cholelithiasis and pancreatitis, confirmed by an ultrasound. Noting the patient's history of heavy smoking and recent hospitalization for empyema, the general surgical service contacts the pulmonologist to do a preoperative evaluation of the patient's ability to withstand a laparoscopic procedure the next morning.
 
CMS transmittal 1719 instructs carriers not to deny preoperative evaluations as routine services or screenings, Mulholland says.
 
According to the transmittal, a pulmonologist must code a preoperative evaluation by using the appropriate preoperative V code as the primary diagnosis, Mulholland says. "This method of coding identifies the service provided," she says.
 
The codes are:

 V72.81 preop cardiovascular exam
 V72.82 preop respiratory exam
 V72.83 other specified preop exam
 V72.84 preop exam, unspecified.

"Pulmonologists will use V72.82 most frequently," Mulholland says.
 
The V code, however, is not enough to justify medical necessity of the preoperative examination by the pulmonologist. Pulmonologists must also code the reason for the surgery and the comorbid pulmonary condition that would require medical evaluation of the patient's suitability for surgery. In this case, the reason for the surgery is coded 574.0x (calculus of gallbladder with acute cholecystitis) and 577.0 (acute pancreatitis), and the comorbid pulmonary condition is COPD.
 
The Medicare Carriers' Manual indicates that when the physician provides a preoperative service, the bill must incorporate the diagnoses that prompted the surgery. Also, any condition that would affect the patient's care must be documented on the claim.
 
In addition to the information described above, the pulmonologist's progress notes should indicate that the pulmonologist's preoperative opinion was requested by the surgeon. "The pulmonary physician will provide a traditional consult (99241-99245) or bill the service as an established patient (99211-99215), depending on the situation," Mulholland says.
 
If the pulmonary physician reports a consult, he or she must keep a copy of the request for services, as well as all correspondence with the surgeon. The request for the consult can, however, be verbal.

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