Pulmonology Coding Alert

Don't forget to append modifier 25 when you report multiple services

When your pulmonologist performs a procedure such as a bronchoscopy, you should closely review the documentation for indications of a separately identifiable E/M service or you may be missing out on an opportunity to report both the procedure code and a separate E/M service. The following two scenarios will help you determine whether the service your physician provided constitutes an additional E/M.

Documentation Must Support Separate Billing

If you have a hard time determining what constitutes a separate E/M service when your pulmonologist performs a procedure, remember that your physician needs to document a significant, separately identifiable service.

For every procedure your physician performs, he must complete a cursory history and physical (H&P) on the day of the procedure, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia. So, to report a separate E/M service, your pulmonologist must document a service that is above and beyond the pre- and post-operative care associated with the procedure.

You can't report a separate E/M for information that your pulmonologist gathers for the H&P required by the hospital. An evaluation of the underlying medical condition or disease, however, goes beyond the normal care associated with the procedure, so you can report a separate E/M code.

Consultations Are Separately Identifiable

Scenario 1: An internist admits a patient to the hospital due to increasing shortness of breath (786.05) and requests that a pulmonologist perform a consultation. The pulmonologist reviews the patient's x-rays and medical records, and then determines that a bronchoscopy is warranted. He then preps the patient and performs the bronchoscopy in the hospital that same day.

Coding solution: The pulmonologist performed a consultation, during which he made the decision for bronchoscopy, and then he performed the procedure. In this scenario, you should report both services. Submit 99251-99255 (Initial inpatient consultation for a new or established patient...) based on the level of service the physician provided, Pohlig says. Then, report 31622 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]).

Note: Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to indicate that the service is separately identifiable from the procedure.

Caution: Make sure that your physician meets and documents the requirements of a consultation before you report the appropriate code. See the accompanying article "Identify What Makes a Consultation" for more on coding consultations.

Post-operative Care May Warrant a Separate Code

Scenario 2: Your pulmonologist sees a patient in the office and based on his examination, schedules a bronchoscopy for later that week. He performs the bronchoscopy a few days later in the hospital and during the procedure finds a mass that he biopsies. Following the procedure, the physician devises a plan of care and later the same day meets with the patient to discuss the findings and the care plan.

Coding solution: The development of the care plan and dealing with the treatment or management options with the patient goes above and beyond the normal post-operative care associated with a bronchoscopy. Therefore, you can report a separate E/M service.

For this scenario, report 31622 for the bronchoscopy procedure and 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient...) based on the level of service the physician provided during the follow-up visit. Attach modifier 25 to the E/M code to indicate that it's a separate service, advises Lisa Center, CPC, coder for the Mt. Carmel Regional Medical Center in Pittsburg, KS.