Pulmonology Coding Alert

Get a grip on E/M and spirometry bundles

You can report the pulmonologist's hypersensitivity pneumonitis treatments with confidence if you know how to use signs-and-symptoms coding, avoid confusing spirometry bundles, and report the physician's E/M services.

Initial Procedures Require Symptoms, Bronchoscopies

The lowdown: When the physician suspects that a patient has hypersensitivity pneumonitis, otherwise known as extrinsic allergic alveolitis (495.x), the physician will report the patient's signs and symptoms in the medical documentation.

Example: Patients generally present to the pulmonologist with fever (780.6), shortness of breath (786.05), chest pain (786.50), weight loss (783.21) and fatigue (780.79), says Anthony Marinelli, MD, FCCP, chairman of the American Thoracic Society's Clinical Practice Committee.

Because the patient's symptoms will probably resemble other respiratory problems, the pulmonologist must take an extensive history, perform a thorough exam and order several diagnostic tests, Marinelli says.

Typically, those tests include bronchoscopy, with or without various diagnostic techniques (31622, 31623, 31624, 31628), and pulmonary function tests (PFTs, 94010, 94240, 94375, 94720). (For procedure code definitions, see "Understand Hypersensitivity Pneumonitis Procedure Coding".)

Tip: Knowing how to report these tests means significant revenue for your office. For instance, if the documentation lets you report 31622, 94010, and an appropriate E/M code, such as 99214, to Medicare, you could expect about $400.

Don't Let E/M, PFT Bundles Cause Denials

To justify the bronchoscopies and PFTs, you must link the patient's signs and symptoms to the appropriate codes.

Strategy: Bill the E/M service (for example, 99214, Office or other outpatient visit for an established patient ...) in addition to the bronchoscopies and PFTs by linking 780.6, 786.05, 786.50, 783.21 and 780.79 to the E/M service and diagnostic tests. This way, the insurer has specific conditions that warrant your physician treating the patient, even though the physician hasn't provided an official diagnosis.

Warning: The National Correct Coding Initiative (NCCI) edits bundle the following tests when the physician performs them on the same day. Typically, to get paid for billing the codes separately, you have to use modifier -59 (Distinct procedural service). And, you can never bill pulse oximetry (such as 94760) with another payable service. To report the lab tests (85025-85027, 86001, 86003), your office must analyze the specimen, not merely send it to a lab.

Watch for these tests:

 complete blood count (85025-85027)

 allergen tests (86001, 86003)

 high-resolution chest CT (71275)

 oxygen saturation assessment (94760, 94761)

 prolonged postexposure evaluation (94070)

 antigen challenge tests (95071)

 skin testing (95004-95010).

How it works: When billing PFT codes 94010 or 94375, remember that the NCCI bundles them into the more comprehensive prolonged postexposure evaluation code (94070). The only time you would report the above codes separately is when they are done for separate and distinct reasons. When the physician performs spirometry (94010) first, the procedure indicates a problem that required additional testing through the prolonged postexposure test (94070). 

In this case, you should assign 94070 for the postexposure test, and 94010 for the spirometry, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. You should also attach modifier -59 (Distinct procedural service) to 94010 to unbundle the NCCI edit.

Put the Pieces Together

Once the pulmonologist diagnoses the patient with hypersensitivity pneumonitis, you should link the appropriate ICD-9 code from the 495.x series (Extrinsic allergic alveolitis) to support any of the physician's follow-up care.

Tip: Choosing codes from a different ICD-9 series to justify hypersensitivity pneumonitis treatments could lead to denials. That's because the code series represents air-borne-related lung conditions, which cause hypersensitivity pneumonitis.

Example: The physician diagnoses a patient with hypersensitivity pneumonitis. Therefore, when the physician sees the patient for follow-up care, you should link a condition code from the 495 series to the appropriate E/M code (for example, you could use 495.0, Farmers' lung, to justify billing 99214).

Stay up to speed with these 495-series codes:

 495.0 - Farmers' lung

 495.1 - Bagassosis

 495.2 - Bird-fanciers' lung

 495.3 - Suberosis

 495.4 - Malt workers' lung

 495.5 - Mushroom workers' lung

 495.6 - Maple bark-strippers' lung

 495.7 - "Ventilation" pneumonitis

 495.8 - Other specified allergic alveolitis and pneumonitis

 495.9 - Unspecified allergic alveolitis and pneumonitis.