Pulmonology Coding Alert

Overlooking symptoms could earn you $223 or nothing.

Most patients who are infected with histoplasmosis will never show any ill effects, but will show signs of the disease. As a result, the coding process could give you a run for your money if the provider doesn't document the correct respiratory symptoms, and pick out the right E/M codes.

Background: Histoplasmosis (115.xx) is caused by breathing in spores from a fungus found in bat or bird droppings. This fungus -- when airborne -- are inhaled or breathed into a person's lung. Although the main area affected is usually the lungs, sometimes other organs get infected. When there are other organs infected, this disease becomes disseminated histoplasmosis (i.e., 115.01, Histoplasma capsulatum meningitis, and 115.02, Histoplasma capsulatum retinitis).

The following scenario will take you on a step-by-step study in reporting histoplasmosis and its treatment:

A 66-year-old man presents to the pulmonologist for evaluation of chronic dry cough, muscle pain and chills. During the consult, the pulmonologist reviews the patient's lengthy medical records and most recent chest x-ray, which shows normal results. Next, she performs an extensive history and physical. The patient admits to maintaining a small-sized bird farm and being exposed to the animals' manure. The physician suspects histoplasmosis and takes a histoplasmosis skin test. She also orders a complete blood test after the visit. She schedules a follow-up visit in two days to interpret the test results and perform a more extensive diagnostic workup. How should you report this?

Watch Out For Symptoms

The symptoms of histoplasmosis can vary. It could come on like a mild cold or flu-like respiratory illness. However, many times it is a combination of the following:

feeling generally ill

• fever (780.60)
• nonproductive cough (786.2)
• headache (784.0)
• chest pain (786.50)
• muscle pains (729.1, Myalgia and myositis unspecified)
• chills (780.64, Chills [without fever])
• hoarseness (784.42)
• dry cough (786.2)

Remember: The pathology lab should bill the blood test, not the pulmonologist. The physician only documents in the progress notes that she "personally reviewed the lab's report."

The pulmonologist should provide the appropriate diagnosis

coding with the lab order (either the reason for the test or the visit) so that the pathology lab analyzing the specimen can get paid. In this case, the ICD-9 codes supporting medical necessity of the lab test are chronic dry cough (786.2), muscle pain (729.1), and chills (780.64).

86510: Screening Confirms Real Infection

You should bill the initial consult using E/M codes for consultation (99241-99245), which includes the three key components history, exam and medical decision-making. In the scenario given, you choose 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family.) due to the comprehensive history and exam, the lengthy medical-record documentation that the pulmonologist reviewed, and the complexity of the diagnostic workup required to confirm the diagnosis.

You should expect to get about $216.09 for reporting 99245 (6.36 RVUs multiplied by the 2011 conversion factor of 33.9764). If the payer is Medicare or follows Medicare rules, you will not be able to report a consultation code. You must report a new (99201-99205) or established (99212-99215) visit, depending on whether the pt has been seen by anyone in the group within the last three years in any setting (inpatient or outpatient).

Also, since the patient underwent a histoplasmosis skin test, you should report this service using 86510 (Skin test; histoplasmosis). This could pay you up to $6.46 in reimbursement (0.19 RVUs multiplied by the 2011 conversion factor of 33.9764). Combining the two services for this encounter, you should be counting on $222.55.

What happens: The health care provider cleans an area of the patient's skin, usually the forearm. She then injects an allergen just below the cleaned skin surface. The provider checks the injection site at 24 hours and at 48 hours for signs of a reaction. Occasionally, the reaction may not appear until the fourth day.

Unless histoplasmosis is confirmed, report the corresponding signs/ symptoms for any testing, notes Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

Deal With Follow-Ups According to Service Provided

Suppose the patient returns after two days. In reading the results of the skin test and blood test, the pulmonologist confirms that the patient has acute pulmonary histoplasmosis. The doctor spends 30 minutes with the patient reviewing the test results, and counseling him on the risks of continued exposure to bird droppings. The doctor decides that no treatment is required since the patient's symptoms have lessened, but prescribes him an antifungal drug. She advises the patient to stay away from the bird farm to avoid further exposure.

Code it: You could choose from any of the established patient visit codes (99211-99215). For this particular scenario, you should report 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 decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.). Then, you should link 115.05 (Histoplasma capsulatum pneumonia) with 99214 to describe the final diagnosis.

Remember, do not bill 86510 again when the patient returns for the reading of the test results. You should also keep from billing another office visit if the only service that occurs during the followup is the histoplasmosis skin test reading. Although some payers ay permit billing a minimal E/M (e.g., 99211) for the reading, the patient will be required to pay a co-pay for this service, says Pohlig.

Alternative: If the patient returns to the office, has the skin test read, and requires an E/M service for counseling or to institute treatment, or for a different problem, then that's the time you should report the appropriate diagnosis and E/M code.