Pulmonology Coding Alert

Myth #1: You're limited to the precertified procedure and diagnosis

If you base your pulmonology diagnosis coding on myths and assumptions, you are just asking for denials and lost reimbursement. Instead, use our experts' proven strategies to debunk three common ICD-9 coding myths -- such as it's OK to fudge your fifth digits.
 
The following pulmonology coding scenarios will show you how to tighten up your diagnosis coding to guarantee quick reimbursement. Myth #1: You're limited to the precertified procedure and diagnosis. Your physician precertified a transbronchial lung biopsy (31628, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial lung biopsy[s], single lobe) based on one diagnosis.

But after the pulmonologist started the procedure, he discovered other problems requiring surgical attention. Because you precertified only the original diagnosis, you can't report the additional procedures, right? Wrong.

Strategy: You can precertify a procedure code range and submit the follow-up diagnoses after the fact, says Elisabeth P. Fulton, CPC, a coding and audit specialist in Winston-Salem, N.C.

Example: Suppose the radiologist preapproves thoracentesis (32000, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) for a patient with pleural effusion (511.9).

After the pulmonologist begins the procedure, he aspirates a small amount of blood and pus from the patient's lung, which means that the patient actually has hemothorax (511.8). The physician inserts a chest tube and performs thoracostomy to remove the fluid (32020, Tube thoracostomy with or without water seal [e.g., for abscess, hemothorax, empyema] [separate procedure]). Because the insurer only preauthorized the procedure based on the pleural effusion diagnosis, should the practice report both conditions?

Yes, but you can avoid this challenge if you pre-certify a code range rather than just one code, Fulton says.

"Before the surgery, tell the insurer's precertification department that the surgeon may perform other procedures if he discovers additional diagnoses," she says. "We tell the insurance company's precertification department that the surgeon may very well perform more than one procedure, depending on what he discovers when he gets in and looks around."

Lesson learned: Insurers rarely ask physicians to pre-certify just one CPT and diagnosis code. Occasionally, however, the payer might ask you to precertify the intended procedure based on the confirmed diagnosis. Therefore, you should precertify 32000 and make clear that your physician may perform and report more procedures if medically necessary.

Caution: If, after the surgery, the insurance company balks at paying for the thoracostomy (32020), the pulmonologist should write an appeal letter citing the date his practice requested preapproval, that the practice attempted to precertify a code range, and that he diagnosed hemothorax during the thoracentesis. Myth #2: You should expect denials if you report signs and symptoms as primary diagnoses. When your pulmonologist confirms a diagnosis, [...]