Pulmonology Coding Alert

Several factors that affect coding come into play when pulmonologists treat the pulmonary manifestations of systemic lupus erythematosus (SLE), including transfer of care, addressing certain diseases as part of the condition, and proper diagnosis coding. SLE is a chronic multisystemic inflammatory disease affecting the body's connective tissue. Diagnosing and then tracking the course of SLE through its active periods ("flare-ups") and remissive states requires frequent monitoring, laboratory testing, and careful and accurate coding of its many manifestations. In addition, an understanding of the disease and treatment will help coders effectively defend the billing of a claim if the carrier contests it. For treating SLE, the primary ICD-9 code is 710.0 (Systemic lupus erythematosus), followed by the codes that describe the signs and symptoms of the disease. Until the condition has been diagnosed, you should only link the patient's signs and symptoms to any services provided. (See "Lupus Signs and Symptoms Key to Coding" in article 2.)

SLE treatment commonly includes extensive E/M services for the many lupus patients who have lung-related symptoms, such as lupus pleuritis (511.8) or lupus pneumonitis (517.8). "According to the ICD-9 manual, however, the underlying disease of SLE must be coded first when reporting 511.8 or 517.8," says Deborah Grider, CMA, CPC, CPC-H, CCS-P, CCP, coding specialist and president of Medical Professionals Inc. in Indianapolis and a National Advisory Board member for the American Academy of Professional Coders. Some coders may mistake 695.4 (Lupus erythematosus [discoid]) for the systemic form that pulmonologists treat. Although lupus erythematosus, commonly referred to as "discoid lupus," is characterized by skin lesions with no systemic involvement, the skin manifestation may appear as a symptom of SLE. In this instance, 695.4 would be coded as a sign or symptom of SLE. Another form of lupus that pulmonologists may treat is lupus vulgaris (017.0x), which involves cutaneous tuberculosis. Transferring Care to the Pulmonologist A rheumatologist may transfer the pulmonary portion of a lupus patient's care to a pulmonologist. But even then, lupus may be difficult to diagnose. At the beginning of the disease, lupus may not be easily recognizable because the symptoms can be mild. Pleuritis and pneumonitis are common pulmonary manifestations of advanced-stage SLE, which affects about 40 percent of lupus patients. These are the conditions pulmonologists are likely to treat for the lupus patient. Diagnosing SLE-Related Pleuritis Pleuritis is the most common pulmonary manifestation of SLE. To diagnose the condition, the pulmonologist will likely take a chest x-ray (71010-71035) to more clearly image the excess fluid in the pleural space. He or she also may perform thoracentesis (32000*, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) to remove and examine the fluid. If you perform the thoracentesis in a facility [...]