Pulmonology Coding Alert

Report anemia and fever to justify procedures  

When pulmonologists diagnose acute chest syndrome (ACS, 517.3), you'll need to know how to code such procedures as sputum analyses and bone scans, along with signs and symptoms.
 
Typically, ACS strikes patients with sickle-cell disease (282.6x). The patients present to your pulmonologist after a hematologist refers them, says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. Before your pulmonologist makes an official acute chest syndrome diagnosis, report signs and symptoms common among ACS patients to justify your physician's services.
 
For example, a sickle-cell patient's hematologist sends the patient to your pulmonologist after complaints of shortness of breath (786.05), rib wall tenderness (786.59), chest pain (786.5x), difficulty breathing (786.09), and fever (780.6). Your physician obtains a comprehensive history; performs a comprehensive exam, which includes reviewing all organ systems; and orders and interprets x-rays, which indicate new infiltrates on the lung (518.3, Pulmonary infiltrates).
 
In addition, you will probably have to report your physician's review of sputum analyses (89350, Sputum, obtaining specimen, aerosol induced technique [separate procedure]) and bone scans (78300, Bone and/or joint imaging; limited area), Mulholland says. Our experts offer three tips for recouping the proper reimbursement for
ACS services:

1. Link 786.59 to Chest X-Rays

Payment for x-ray interpretations depends on who reads the films. To report the physician's x-ray interpretation, attach modifier -26 (Professional component) to 71010 (Radiologic examination, chest; single view, frontal), unless your physician owns the x-ray equipment or the radiologist plans to bill for the interpretative work in addition to the technical component. Link the above signs and symptoms, such as chest pain (786.5x) and rib cage tenderness (786.59), to 71010-26, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.
 
Because your pulmonologist performed a comprehensive history and exam and engaged in high-complexity decision-making, you may code 99245 (Office consultation for a new or established patient ...).
 
To support payment for the highest level of consultation, your pulmonologist's documentation should include notes of all work he or she performed, such as reviewing x-rays and examining all the body systems, as well as reporting findings to the hematologist.
 
Remember, if you want to report a consultation code, another physician must request a consultation, your pulmonologist should provide an evaluation and recommendations for treatment, and your physician must send a report detailing his or her findings to the requesting physician, Callaway says.

2. Use 958.1 for Fat Embolism Injuries

When reporting to carriers, you should also rely on signs-and-symptoms coding because physicians have a difficult time distinguishing between ACS and pneumonia (480.x) during an acute episode, Mulholland says.
 
Physicians often find fat embolism (958.1) in ACS patients with sickle-cell disease, which helps them differentiate between acute chest syndrome and pneumonia. For instance, fat embolism from bone necrosis (730.1x, Chronic osteomyelitis) injures the patient's bone, which can release an embolism that injures the lungs. ACS patients with pulmonary fat embolisms usually have severe bone and chest pain, Mulholland says.
 
Furthermore, to help determine whether the patient has pneumonia or ACS, your pulmonologist will probably perform a bronchoscopy (31622-31656), she says. In that case, you would support the procedure with ICD-9 codes 958.1 (Fat embolism), 786.5x (Chest pain) and 282.6x (Sickle-cell disease), among others.
 
For instance, your physician uses bronchoscopy (31622, ... [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]) to inspect the patient's lungs. Upon inspection, the pulmonologist finds fat in the patient's lungs (958.1). Therefore, your physician proceeds to perform a flexible bronchoscopy with bronchial alveolar lavage (31624), and diagnoses the patient with ACS.
 
In that case, you should link 958.1, 730.1x and 786.5x to bronchoscopy code 31624. Remember that you cannot report 31622 separately because CPT bundles that code into 31624.

3. Report Oxygen Therapy With E/M Service

Pulmonologists routinely use oxygen therapy to treat ACS. Your physician will administer oxygen to the ACS patient, but you can't report a code for this service. Instead, your physician should note the oxygen administration in his or her medical decision-making documentation, so include the therapy with the E/M service, Mulholland says.
 
If the patient develops severe respiratory failure, your pulmonologist may employ mechanical ventilation with positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP). When the patient's condition requires ventilation management therapy, you will need to use the following codes, depending on the length of the therapy, Mulholland says: