Pulmonology Coding Alert

Medicare coding rules are complex and challenging, and sometimes it's difficult to know which services you can rightfully report. But if you're up to speed on these key coding practices, you'll be raking in deserved pay:

1. Mine those modifier 59 opportunities. Some coders assume that if the Correct Coding Initiative (CCI) forbids reporting two codes on the same date, that's the end of the story. But in fact, you may be missing out on some legitimate cases where CCI allows you to use modifier 59 (Distinct procedural service) to override an edit.

Always scan the CCI edits to see which code pairs can be overridden when appropriate. Of course, you should use modifier 59 only when the services are separate, distinct, and medically necessary.

Example: The need for separate pulmonary function testing (for instance, 94060, Bronchodilation responsiveness, spirometry as in 94010, pre- and postbronchodilator administration) and simple pulmonary stress testing (94620, Pulmonary stress testing; simple [e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry]) is a CCI edit that permits separate reporting, but only when it is medically necessary to override the edit. In this example, you would report 94060, 94620-59, when permitted.

2. Keep modifier 50 in mind. Many procedures are inherently unilateral, and you won't receive full reimbursement for bilateral versions of those procedures unless you append modifier 50 (Bilateral procedure).

Watch out: Coders often forget modifier 50 when the pulmonologist performs bilateral thoracenteses on a patient on the same day. To report bilateral services, append modifier 50 to 32421 (Thoracentesis, puncture of the pleural cavity for aspiration, initial or subsequent) on a single line item with a unit of "1", advises Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. When appropriate, this will yield 150 percent of the Medicare allowable rate: 100 percent for the initial procedure and 50 percent for the second. Remember, bilateral surgeries are defined as procedures performed on both sides of the body during the same operative session or on the same day (such as 31622, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]). Procedure codes containing the terms "bilateral" or "unilateral or bilateral" in their definitions are not subject to bilateral pricing (meaning 150 percent reimbursement), says Pohlig. Additionally, not all procedures qualify for bilateral payment. Check the payment policy indicators for each code in the Physician Fee Schedule at www.cms.hhs.gov/PFSlookup/02_PFSSearch.asp.

3. Appeal when you feel you've been wronged. Because many practices fear being labeled "troublemakers" or even worse yet, non-compliant with the False Claims Act's regulations, they accept Medicare payers at their word -- and this isn't always a good idea.

If your MAC denies your claim or requests a refund, research the issue before you take the payer's word for it.

"At the outset, I would caution against rolling over with regard to 'alleged' overpayments," says Robert Liles, Esq., a health care fraud defense attorney with Liles Parker in Washington, D.C. "If it is a clear overpayment, sure, give the money back. However, if the claims were properly submitted, fight it!" he says.

You should appeal any time you feel your payer has wrongly denied your claim or incorrectly requested a refund. Medicare payers "are getting to be almost as bad as third-party payers," Liles says. "There seems to be a knee-jerk reaction to certain claims and they are automatically denied, regardless of their merit."