Pulmonology Coding Alert

Pulmonologists often require test results to diagnose illnesses and then determine treatments. The level of the physicians involvement with the test, along with some other ground rules, can subtly alter the way the activity is coded and billed. Knowing which codes allow modifier -26 for professional interpretation, and which dont, can ensure correct billing.

Frequently, pulmonologists rely on tests that measure arterial blood gas (ABG). The primary procedure code for testing ABG is 82803 (gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 [including calculated O2 saturation]). The code is appropriate to use if two or more of the listed gases are being measured. If, in addition, you are measuring oxygen (O2) saturation directly (as opposed to calculating it) via any means other than pulse oximetry, code 82805 (gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 [including calculated O2 saturation]; with O2 saturation, by direct measurement, except pulse oximetry) should be used. The code to use when only measuring O2 saturation is 82810 (gases, blood, O2, saturation only, by direct measurement, except pulse oximetry). Normally, but not exclusively, pathologists and laboratory technicians use these codes. Pulmonologists take advantage of these measurements for a variety of reasons; some of the more common are ventilator management and prescription determinations. Sometimes confusion arises regarding how the pulmonologist can bill for interpreting the test results. As with most lab tests, there is no separate CPT code for professional physician review of the ABG test results.

Test Results Must Be Documented

According to Lynda Munsey, CPC, an independent coding analyst in Jacksonville, Fla., When arterial blood gas is measured on an inpatient, the lab determines the results, and the physician determines a treatment based on these results. Patient records should indicate treatment decisions and changes resulting from test interpretations. In other words, the test results and the decisions based on those results should be reflected in chart documentation, such as ...ventilator settings changed to [some setting] based on ABG... or change of medication to [something] indicated by the ABG results of [some setting].

When a pulmonologist uses the results of an ABG test to determine treatment, the test-interpretation work should be considered part of the E/M of a patient and be covered by the E/M codes. The time spent reviewing ABG results and their impact on the patients care legitimately can be used in determining the level of medical decision-making for an associated evaluation and management visit. Likewise, if he or she is using the results to determine if a ventilator is providing enough oxygen to the patient, then the interpretation is included in the ICU and ventilation management charge.

The work associated with interpreting ABG test results contributes to selecting the appropriate E/M visit level. Although there is no separately reimbursable ABG test interpretation CPT code, there is the code for actually running the test, 82803, says Gregory L. Schnitzer, RN, CPC, CPC-H, CCS-P, manager of coding compliance at CodeRyte Inc., a Maryland-based coding and reimbursement consulting firm.

When Is a Modifier -26 Appropriate?

Whether to employ modifiers is sometimes a source of confusion. With some lab tests, it is appropriate to use the modifier -26 (professional component). According to a recent issue of CPT Assistant: The use of the -26 modifier is required for CPT codes 80049-87999 in those instances when the physician is billing only for the professional component of the laboratory test (i.e., medical direction, supervision or interpretation). The Medicare physician fee schedule database (MPFSDB) indicates which CPT codes have technical (modifier -TC) and professional (modifier -26) components that may be billed separately using the appropriate modifiers. (See Which Lab Tests Will Be Paid With Modifier -26? on this page.)

Since there is no separately billable professional service for interpreting ABG test results, cautions Schnitzer, CPT code 82803 is not one of those codes that Medicare has indicated can take either a -TC or
-26 modifier.

Editors note: Some of the comments gathered for this article were reprinted, with permission, from a Web-based discussion at the Coding and Reimbursement Network.

Which Lab Tests Will Be Paid With Modifier -26? Taking the information from the Medicare physician fee schedule database (MPFSDB) and counting only the lab tests in the 80000 to 87999 series of CPT codes not counting the pathology tests in the 88XXX series of codes, there are 15 lab CPT codes that can take a -26 modifier for professional services: 83020 (hemoglobin fractionation and quantitation; electrophoresis) 83912 (molecular diagnostics; interpretation and report) 84165 (protein; electrophoretic fractionation and quantitation) 84181 (protein; Western Blot, with interpretation and report, blood or other body fluid) 84182 (protein; Western Blot, with interpretation and report, blood or other body fluid, immunological probe for band identification, each) 85390 (fibrinolysins or coagulopathy screen, interpretation and report) 85576 (platelet; aggregation [in vitro], each agent) 86255 (fluorescent noninfectious agent antibody; screen, each antibody) 86256 (fluorescent noninfectious agent antibody; titer, each antibody) 86320 (immunoelectrophoresis; serum.) 86325 (immunoelectrophoresis; other fluids [e.g., urine, CSF] with concentration) 86327 (immunoelectrophoresis; crossed [2- dimensional assay]) 86334 (immunofixation electrophoresis) 87164 (dark field examination, any source [e.g. penile, vaginal, oral, skin]; includes specimen collection) 87207 (smear, primary source, with interpretation; special stain for inclusion bodies or intracellular parasites [e.g., malaria, kala azar, herpes])