Pulmonology Coding Alert

Learn when prolonged services should not apply.

Reporting your pulmonologist's asthma attack treatments can be crafty business, as you can be confused about what, how and when to choose from the E/M and treatment codes that describe different situations.

Learn a few secrets of the trade from these scenarios:

Scenario 1: A patient suffering from hay fever with exacerbated asthma (493.02, Extrinsic asthma; with [acute] exacerbation) requires two nebulizer treatments and 55-minute treatment time. What coding option would you report?

Scenario 2: A child patient with asthma experiences active wheezing and shortness of breath. The patient's parent brings the child to the office, and demands the physician to see her child right away because the child is restless and screams in pain.

Dodge A Bullet By Putting Modifier 76 In Its Right Place

Some practices would report Scenario 1 using a level four established patient office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decisionmaking of moderate complexity...) with prolonged services (99354, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]). They would think that the 99214 visit would include 25 minutes of face-to-face time, while 99354 would cover the additional 35 minutes. However, this is not correct coding -- a common mistake of coders, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia. "You cannot report prolonged care to account for monitoring time associated with separately billable procedures (i.e., nebulizer treatments)," she explains.

Instead, you should report this example as:

• 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device]);
• 94640-76 (Repeat procedure or service by same physician); and
• An E/M (e.g., 99214) associated with the patient evaluation to determine the extent of the asthma exacerbation and the treatment protocol.

"Asthma attacks usually involve a detailed history, exam, and moderate to high complexity medical decision making," explains Donelle Holle, RN, in Fort Wayne, Ind, on the E/M coding.

Note: You should also not mistakenly report 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour) as this treatment was not provided continuously over one hour.

Do Not Call Upon 99058 For Office Dispruptions

The second scenario's "emergency" and "interruption" elements may prompt you to include 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) on your claim. This code is for urgent situations or when the physician needs to see an unscheduled patient right away because the patient experiences an acute and pressing problem.

Careful: Before submitting 99058, consider the issues and know your contractual terms -- payers typically bundle 99508 and disallow payment since it represents an access-to-care issue, warns Pohlig. "If 99508 is considered a 'bundled' code, you may not seek reimbursement from the patient. If the code is simply 'excluded' from the payer's fee schedule, you may be permitted to bill the patient. However, billing the patient for urgent care is likely to cause more 'customer service' issues and could also violate the terms of agreement between the provider and the payer. Failing to see an established patient who presents to the office with an acute complaint (scheduled or unscheduled) may result in an unfavorable health outcome prompting legal concern," she says.

CPT® 99058, among other "special service" codes, should not be reported just because it exists in CPT®. Consider the billing, contractual and medico-legal issues that involve any CPT® code prior to its use.