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.

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.

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 and the pulmonary physician leaves a tube in for drainage, you should report 32002 (Thoracentesis with insertion of tube with or without water seal [e.g., for pneumothorax] [separate procedure]), says Anthony M. Marinelli, MD, FCCP, chairman of the American Thoracic Society's Clinical Practice Committee.

Pulmonary physicians usually treat pleuritis with nonsteroidal anti-inflammatory drugs and/or cortico-steroids. The condition usually responds to these treatments or clears up on its own.

Pulmonologists frequently use sputum tests (94664, Aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation; 94665, & subsequent) and chest x-rays to diagnose SLE-related pneumonitis. According to coding experts, 94664 and 94665 will likely change with CPT 2003, however, when 94640 will probably be used for treatment of airway obstruction and sputum induction for diagnostic purposes. Code 94664 will likely be used for demonstration and evaluation of nebulizer, and 94665 will be deleted, experts say.

The physician may also order blood tests. If the pulmonologist sees the patient in the office and draws the blood for testing, you could report G0001 (Routine venipuncture for collection of specimen[s]) for Medicare or 36415* (Routine venipuncture or finger/heel/ear stick for collection of specimen[s]) for private payers. As with lupus pleuritis, you should link signs and symptoms codes with these diagnostic procedures until the pulmonologist makes a definitive SLE diagnosis.

Pulmonary physicians usually treat pneumonitis with a course of antibiotics. If laboratory tests reveal a noninfectious form of pneumonitis, physicians may use high doses of corticosteroids, as well as immunosuppressive drugs like azathioprine if the steroids do not control the lung inflammation.

Because SLE involves multisystem conditions, it usually requires moderate- or high-level medical decision-making. This, combined with the history and physical, often leads to higher-level E/M coding (99203-99205 for new outpatient services, and 99213-99215 for established outpatient services).

In addition, pulmonologists should document the time involved with these visits because counseling and coordination of care can dominate a visit with a lupus patient. Helping the patient understand the various signs and symptoms of the disease, the role of various medications and when he or she should see the doctor can take up a majority of the visit. If the physician properly documents the amount of time he or she spends with the patient, showing that more than 50 percent of it was devoted to counseling and coordination of care, you can base E/M coding on time alone. (For more information about coding counseling and coordination of care services, please see "Keep Your Peace of Mind: Don't Lose Out on Counseling Payment" in the August 2002 Pulmonology Coding Alert.)

If the pulmonologist provides an E/M service during the same visit as he or she performs procedures to diagnosis or treat lupus-related pleuritis or pneumonitis, you should append the E/M code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to show that the service should be reimbursed separately.