Pulmonology Coding Alert

The pulmonologist inserts the bronchoscope into a sedated patient's trachea but stops when the electrocardiogram (EKG) screen shows the patient is developing a ventricular arrhythmia. An attending pulmonologist has to stop a thoracentesis because a cancer patient requires administration of a pain medication to be able to remain still enough for the pulmonologist to proceed safely with the procedure. And a resident is unable to safely complete a thoracentesis on a nervous patient, and the pulmonologist must take over the procedure.

What each of these situations has in common is that pulmonologists can lose out on fair payment for their time and effort if they do not know how to code and bill interrupted services. In addition, pulmonologists occasionally have to halt a procedure to perform cardiopulmonary resuscitation. Again, they have to know how to bill for this service in such a scenario.

If a bronchoscopy is interrupted because the patient could not medically tolerate the procedure, the pulmonology coder would append modifier -53 (Discontinued procedure) to the CPT code for a diagnostic bronchoscopy (31622), according to Michelle Logsdon, CPC, CCS-P, coding manager for Cash Flow Solutions Inc. in Lakewood, N.J. "This indicates that the procedure was attempted but not completed," she says.

The pulmonologist would use the ICD-9 code that justifies the medical necessity for performing the procedure, such as an abnormal x-ray (793.1, Nonspecific abnormal findings on radiological and other examination of lung field), Logsdon adds. The pulmonologist could use the diagnosis indicating the reason the procedure was halted as the second diagnosis for example, specifying a ventricular arrhythmia (427.1, Ventricular tachycardia).

In another example, a patient with metastatic breast cancer (174.9) requires insertion of a chest tube to treat a spontaneous pneumothorax (512.0). The pulmonolo-gist initiates the procedure, but the patient is in too much pain to hold still and refuses to continue until her pain is under control. The pulmonologist then orders the nursing staff to start a continuous IV morphine drip. In this case, the pulmonologist could bill 32002 (Thoracentesis with insertion of tube with or without water seal [e.g., for pneumothorax] [separate procedure]), attaching modifier -53.

"Use of the -53 modifier will alert the insurer that the procedure could not be completed and was terminated at the physician's discretion because there was a problem that imposed a threat to the patient's health," says Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the department of medicine at the University of Pennsylvania in Philadelphia. "If a patient is in pain and thrashing around, the pulmonologist would not want to perform the procedure even if it were minimally invasive."

The pulmonologist returns in two hours and the patient says her pain is now manageable with the morphine drip. The pulmonologist is then able to insert the chest tube. The physician ethically could bill Medicare for the completed procedure (32002) in addition to the aborted thoracentesis earlier in the afternoon. The pulmonologist could append modifier -59 (Distinct procedural service) to the separately billed 32002 to show that the second thoracentesis is a separate procedure. "Use of the -59 modifier can't hurt and will provide additional clarification for the insurer," Pohlig says.

Should the pulmonologist discount the rate when billing for these interrupted procedures? No, says Toni Revel, CPC, a coding expert and nurse practitioner based in Warrington, Pa. "Providers should have one fee for every procedure code. Just as is true when applying modifier -52 (Reduced services) when a procedure did not take as much time or expertise as expected, the physician reports the usual fee for the service and allows the third-party payer to decide whether to reduce the fee."

Pohlig agrees that the pulmonologist should not discount the service. "Say it's a three-step procedure, and the pulmonologist completed two of those steps. The pulmonologist should not automatically reduce the charge by one-third because he doesn't know how much money the carrier is designating for the first two parts. It may not be an equal distribution of 33.33 percent for each part." So the pulmonologist might be undervaluing his services by personally discounting the rate. "It's best to let the carrier review the portion of the services that were completed and decide how much the pulmonologist should be reimbursed," Pohlig emphasizes.

The key to obtaining fair payment for interrupted services is documentation. "It's important when you have a variance from a normally reported procedure code to clearly document what the variance is and why it occurred," Pohlig says. "The pulmonologist should record who was involved in the service, and how far along the procedure went before it was interrupted, so that he or she can capture as much reimbursement as is fair for [the service]."

To prevent payment delays, you should submit the supporting documentation when billing services with modifier -53. Pohlig notes, for example, that some consultants suggest the physician should not submit his or her full charge for an interrupted procedure. "Yet the carriers have edits in their system," she says, "so that modifier -53 appended to the CPT code flags the claim. And that claim will be suspended if the physician didn't submit paper records [explaining how much of the procedure was performed and why the service was interrupted], resulting in a further delay in payment. The edit exists to trigger a manual review of the claim. Through this review, the payment should be determined by the carrier."

When the physician interrupts a procedure to perform CPR, he or she has two options for billing the service or time spent stabilizing the patient. "The pulmonologist could bill 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest])," Revel says. However, "if the physician provides critical care services, he or she could report 99291 for the first 30 to 74 minutes and +99292 for each additional 30 minutes beyond 74 minutes spent providing critical care services. Critical care includes many other services, and providers should refer to their CPT manual for these bundled codes."

Yet, if CPR and critical care services (99291-99292) are reported together, the time spent performing CPR should not be included in the critical care time. The 30 minutes of critical care time must be independent of the time associated with CPR.

If an insurer will not pay for CPR when reported with another service, the pulmonologist who completes the bronchoscopy in addition to performing CPR could append modifier -22 (Unusual procedural services) to the CPT code for bronchoscopy (31622-22). In this situation, the physician should submit the supporting documentation. "If the pulmonologist wants to be reimbursed for his time and effort, he has to be very specific as to what happened and what he did," Pohlig cautions.

Residents occasionally cannot complete a procedure, and the attending physician who is supervising the resident takes over. This situation is handled differently from when the attending physician does not complete a procedure. For example, the attending pulmonologist who has privileges in a teaching hospital is observing a nervous resident attempt to insert a chest tube in an anxious patient who will not hold still. The pulmonologist decides to take over the procedure when the resident misses the correct spot for the second time. If the pulmonologist successfully completes the procedure, he or she would report the thoracentesis code (32000) without any modifiers.

"As long as the teaching physician provides the appropriate supervision, he or she can bill for a procedure performed by a resident, and, in this case, the pulmonologist performed the procedure," Pohlig says. In addition, the pulmonologist could attach modifier -GC (This service has been performed in part by a resident under the direction of a teaching physician) to the procedure code (32000-GC) to indicate that the resident was involved in some portion of the procedure.

Modifier -GC identifies that a service was performed in part by a resident under the supervision of a teaching physician. (A resident is defined as an individual in a graduate medical education program, e.g., an intern, resident or fellow but not a nurse practitioner, physician assistant or student in these fields.) However, when the teaching physician provides the service and does not rely on any work or documentation from the resident who saw the patient separately from the teaching physician, modifier -GC is not required.