Pulmonology Coding Alert

What's ECG got to do with it?

Knowing how to code a referral for patients with sarcoidosis is the first step to making sure that you're billing your claim correctly. But your coding proficiency should not end here. Aside from the patient referral, you'll have to be on the lookout for the appropriate ICD-9 codes for treatment services.

The whole coding process for services involving sarcoidosis can be real challenge, but you can rise above it if you shun these three most common misconceptions.

Myth 1: Sarcoidosis Suspect Requires Low Level Consult Code

First and foremost, don't tackle anything you don't understand. Sarcoidosis (135) is a condition in which inflammation occurs in the lymph nodes, lungs, liver, eyes, skin, or other tissues. More often, a patient with (suspected) sarcoidosis would to the office following a referral from her primary care physician (PCP).

Although sarcoidosis may exhibit no definite symptoms, patients may complain of general discomfort that could involve almost any organ system in the body. For instance, if a patient complains of fatigue (780.79), dry cough (786.2), headache (784.0), and shortness of breath (786.05), the PCP -- suspecting of sarcoidosis -- would likely send the patient to a pulmonologist to get her opinion on the patient's blood chemistry and chest xray results.

What happens at the referral: Upon presenting to the office, the patient would likely undergo a comprehensive history and exam. The patient's comprehensive history might reveal past conditions such as liver disease (571.x), exposure to asbestos (V15.84), and occasional pleuritic pain (786.52). Meanwhile, the review of chest xrays might uncover mediastinal lymphadenopathy (785.6, Enlargement of lymph nodes) or abnormal findings of the lung (793.1, Nonspecific [abnormal] findings on radiological and other examination of lung field). To report the comprehensive history and exam, and high complexity decision making, you would use 99245 (Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity). Report 71010 (Radiologic examination, chest; single view, frontal) appended by modifier 26 (Professional component) for your physician's interpretation of the xrays, if performed.

Must: Your pulmonologist's documentation should include notes of all work he or she performed, such as reviewing xrays and taking a comprehensive history, and a report detailing his or her findings for the PCP.

Myth 2: Diagnosing Sarcoidosis Stops With E/M Service

Lung biopsy remains a key method used by pulmonologists to properly diagnosis the sarcoidosis -- performed after completing the high level  E/M. Based on the findings in our example, the pulmonologist might use bronchoscopy to inspect the lungs, and then decide to perform a transbronchial lung biopsy. You should code this procedure with 31628 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy[s], single lobe).

Caveat: You should consider the bronchoscopy element as diagnostic work. And since surgical procedure payment always includes diagnostic work, you should not report 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) separately from 31628.

In absence of a definitive diagnosis, you would report the signs and symptoms prompting the procedure (e.g., 785.6 for lymphadenopathy).

Myth 3: Follow Up Services Exclude ECG, Spirometry

The pulmonologist would need to monitor the disease's activity, and the patient's lung performance. She might do this using spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) during the patient's follow-up visits. You should link 135 and 517.8 (Lung involvement in other diseases classified elsewhere) to validate spirometry for sarcoidosis monitoring.

Sometimes, the pulmonologist would perform an electrocardiogram (ECG) to look for heart abnormalities, and an ophthalmology exam to look for uveitis (364.0x) in addition to the spirometry, says Charlie B. Strange III, MD, FCCP, professor of pulmonary and critical care medicine at the Medical University of South Carolina in Charleston. You would report the ECG with 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). Meanwhile, the job of performing the ophthalmology exam would go an ophthalmologist (upon referral of the PCP). As with spirometry, you should link the conditions 135 and 517.8 to justify the ECG. If the patient experiences common symptoms associated with sarcoidosis, such as shortness of breath or abnormal beats, report the symptoms as the primary reason for the ECG.

Treatment medicines: The pulmonologist should prescribe prednisone (corticosteroid) to treat sarcoidosis. Additional medications may also be necessary (i.e., methotrexate, azathioprine or a tumor necrosis factor [TNF] inhibitor).

How about the E/M? Evaluation of the underlying condition would warrant an E/M level (e.g., 99213, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity.).