Pulmonology Coding Alert

The keys are ICD-9 codes, time-based documentation

When a patient becomes critically ill or injured during the post-op period of a procedure provided by another physician, you may be tempted to treat the patient and forget about coding for critical care, but this could be costing your pulmonologist justified reimbursement.

In many cases, the critical care is separately reimbursable, but the proper coding for this scenario depends on the payer. With a little research, and an assist from the right modifier, you can rightfully code separately for critical care occurring during a global period.

Bill for 99291 During Surgery

Example: A patient with non-reducible, right-sided inguinal hernia, CHF, and controlled type II diabetes comes to the hospital for a hernia repair. Three hours after the operation, the patient shows signs of shortness of breath, problems urinating, cyanotic extremities, and an irregular pulse. 

The patient goes into cardiac/respiratory arrest, and the pulmonologist is called to the floor. The pulmonologist resuscitates the patient. The clinical bedside care involves a brief period of CPR and intubation/ventilation.

The patient stabilizes after 48 minutes of care outside of any separately billable procedures such as CPR and intubation.

In this scenario, you are able to bill for the critical care using 99291 (Critical care, evaluation and management of the critically ill or injured patient; first 30-74 minutes). Medicare will treat the pulmonologist separately from the surgeon, and pay for the services. However, on first pass, other payers may mistakenly deny the critical care service because it occurred during the (major) surgical global period of 90 days for the initial hernia repair.

Contact Payer to Choose Modifier

Even though the pulmonologist may have no relationship with an initial treating surgeon, some non-Medicare payers will want modifier 24 (Unrelated E/M service by the same physician during a postoperative period) on the claim, says Marie West with Medical Data Services in Edmund, Okla.

However, other carriers may prefer modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for critical care provided during the global period for minor surgeries. Check with your insurer before filing the claim to see which modifier it requires.

For instance, Cigna Medicare asks you to use modifier 25 for critical care on the same date as a procedure.

Decide Which ICD-9 Codes Apply

Payers may offer advice regarding diagnosis. According to Noridian Administrative Services in its latest provider question-and-answer file, you should use an ICD-9 code between 800.0 and 959.9 (except 930-939) with critical care codes. These diagnosis codes will clearly indicate that the critical care was unrelated to the surgery, Noridian says.

Tip: Pulmonologists may want to focus on their specific reason for treating the patient, suggests Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.. "One of the respiratory failure codes, 518.81-518.84, should be used, if a pulmonary problem precipitates the need for critical care or occurs during the critical care period."

"Any serious, unexpected, adverse event after surgery that meets the CPT definition of 'critical' would work, as long as it had nothing to do with the reason for the surgery," says Dianne Wilkinson, the compliance officer and quality manager for MedSouth Healthcare in Dyersburg, Tenn.

Don't overlook: The critical care codes need documentation to support the severity of the illness as well as the complexity of the physician's decision-making, says Jennifer Swindle, senior coding consultant with PivotHealth in Nashville, Tenn. You should document in detail all the time the physician spent.