Pulmonology Coding Alert

Many common pulmonology procedures are considered to have evaluation and management (E/M) services bundled into them as an inherent part of the procedure. For these procedures, coders cant report E/M in addition to the procedure code. In some cases, a physician has performed an extra E/M service that he or she considers separate from the procedure. To get reimbursed for the extra service, coders should add the E/M code to the claim with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Since Oct. 30, 2000, the HCFA has required the use of modifier -25 for these separate E/M services. Coders can bill for these services separately only if they use modifier -25.

Now physicians must verify by the use of modifier -25 that a significant, separately identifiable E/M was performed, rather than just the basic information-gathering and delivery of results performed as a standard part of all procedures, according to Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

This new policy, proposed by HCFA in Section H of the Nov. 2, 1999, Federal Register, was implemented in the national Correct Coding Initiative (CCI) edits with version 6.3. More than 50,000 codes were affected by the policy shift, including those commonly used by pulmonary physicians.

Because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record, HCFA stated.

Modifier -25 Is Critical to Pulmonary Coding

Some coders who have reported separate E/M procedures performed on the same day as pulmonary procedures have not received payment since the ruling went into effect. If they had used modifier -25, their claims might not have been denied.

The news about modifier -25 is extremely important to pulmonary billing for critical care, says Walter J. ODonohue Jr., MD, FCCP, representative to the AMA CPT advisory committee for the American College of Chest Physicians and chief of pulmonary/critical care at the University Medical Center in Omaha, Neb. In some cases, the E/M service is the whole treatment, and a physician would bill only for that service.

ODonohue suggests the example of another physician sending a patient to the pulmonologist just to have a bronchoscopy (31622, bronchoscopy [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]). Then the pulmonologist would take the patients history and perform the bronchoscopy, sending the results back to the referring physician. The pulmonologist couldnt also bill for separate E/M services.

But if a doctor sends a patient to be evaluated for a cough, and the pulmonologist does an examination and, as a result, schedules a bronchoscopy on the same day, thats a good reason to bill for both the bronchoscopy and the E/M service, using modifier -25, ODonohue says.

Spirometry (94010, spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) is another procedure that requires the coder to determine whether the pulmonary function test is part of the pulmonologists evaluation or just a procedure performed without significant E/M. ODonohue says, If another physician has a patient whos short of breath, and he or she sends the patient to the pulmonologist for a pulmonary function test, the pulmonologist can bill only for the spirometry.

Using Modifier -25 and Two E/M Codes

In rare cases, you can use two E/M codes with the -25 modifier. ODonohue suggests this example: Suppose you admit a patient to the hospital with chronic obstructive lung disease in the morning. Youll do a history and thorough physical examination. The coder will report one of the codes appropriate to an admission workup (99221, 99222 or 99223, initial hospital care, per day, ranging from low to high severity, with medical decision making ranging from low to high complexity, and from 30 to 70 minutes at the patients bedside and on the patients hospital floor or unit).

Suppose the same patient goes into remission, but later crashes, and you perform critical care for an hour in the afternoon, ODonahue continues. The coder will report critical care (99291, critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). Critical care codes fall under the category of E/M codes. But now, because the physician has performed another significant E/M service on the same day, the coder will add modifier -25 to the two codes (99221, 99222 or 99223, plus 99291).

The CCI edits allow the use of modifier -25 for the whole range of commonly performed pulmonary procedures from 94010 through 94799 (unlisted pulmonary service or procedure).