Pulmonology Coding Alert

Avoidthe misuse of modifier 52 by reporting combination code 78582, regardless of number of projections.

When your pulmonologist attends to a patient with suspected pulmonary embolism, she may order a ventilation/perfusion scan (or VQ study) to confirm the diagnosis. To arrive at an accurate code for the encounter, you’ll need to know whether the physician provided a perfusion or ventilation service. Follow these handy pointers on lung scanning to clear coding blindspots.

#1. Review the Intent of the Scan

If the pulmonologist wants to learn how well a patient is getting oxygen into their blood, she’d generally like to measure two things: how well the blood is getting down into the capillaries surrounding the alveoli in the lungs (perfusion), and how well the oxygen is getting down into those same alveoli (ventilation). 

A pair of nuclear scan tests -- pulmonary ventilation/perfusion scan -- will accomplish this purpose. During a ventilation study, the provider places a mask over the patient’s mouth and nose so he breathes in the radioactive material while images are taken to measure air flow in and out of the lungs.

#2. Look for Details on Inhalation 

You would bill code 78579 (Pulmonary ventilation imaging [e.g., aerosol or gas]) for a diagnostic imaging study performed with the use of a radiopharmaceutical that records the bronchopulmonary distribution of an inhaled radioactive aerosol or gas within the lungs.The patient performs breathing according to specific instructions while images are taken in multiple positions. 

Documentation pointer: If you want to confirm if the physician performed a ventilation study, look for signs in the documentation that point to terms such as “gases,” or “inhalation.” Also, you should confirm if the patient inhaled a radioactive gas (generally xenon), or if the patient actually inhaled oxygen that had been aerosolized with particles of a radioactive substance. Look for other terms such as “DTPA,” “Technetium DTPA,” “particulate,” and “mist.”

#3. If Its Injected, It’s a Perfusion

You should report code 78580 (Pulmonary perfusion imaging [e.g., particulate]) for an imaging study performed with a radiopharmaceutical that records distribution of pulmonary arterial blood flow in the lungs. Look for the injection of the radioisotope in the documentation to confirm the test was a perfusion. This is unique to perfusion. In the documentation, you may find references to injections of “TC-99m MAA,” or “Technetium MAA,” and macroaggregated albumin (the radioactive particles injected into the patient’s vein). The term “macrospheres” will also clue you in to the fact that you are dealing with a perfusion study.

#4. Keep a Sharp Eye Out for Combined and Differential Procedures 

Go for “combination” code 78582 (Pulmonary ventilation [e.g., aerosol or gas] and perfusion imaging) if the pulmonologist has ordered a joint or combined procedure to determine both pulmonary perfusion and ventilation. In such a scenario, images are obtained once after inhalation of a radioactive aerosol to determine pulmonary ventilation and again after injection of a radioactive particulate to determine lung perfusion.Perfusion and lung ventilation scans almost always go together. A pulmonologist would often perform these procedures jointly to detect a characteristic pattern of perfusion deficits. Together, these procedures provide an accurate noninvasive screening test both for the detection of emboli and for documentation of resolution during and after therapy. 

If the physician ordered differential scans, report code 78597 (Quantitative differential pulmonary perfusion, including imaging when performed)for a quantitative lung perfusion study performed with the use of a radiopharmaceutical that measures relative distribution of pulmonary arterial blood flow in each lung. Your pulmonologist may advise a differential perfusion in patients with unequal distribution of blood flow in the lung. The scan reports quantitative evaluation of images. 

Further, you can report code 78598 (Quantitative differential pulmonary perfusion and ventilation [e.g., aerosol or gas], including imaging when performed) for both differential pulmonary perfusion and ventilation study. Code 78598 represents the same work as 78597, only with a ventilation study added. Both these codes include imaging, when performed and you cannot report any additional codes for the imaging. The imaging can be a magnetic resonance imaging (MRI) or other radiological imaging that your radiologist obtains during the scan. 

Note: You should report combination code 78582 regardless of the number of projections that were performed as part of the pulmonary perfusion procedure. This helps eliminate the misuse of modifier 52 (Reduced services) to indicate reduced services. For instance, if you do only one component of the 78582 procedure, you can just report the perfusion code 78580 or the ventilation code (78579) -- no need to append modifier 52.

“If the test is performed in a facility-based setting, modifier 26 should be attached to the code (i.e., 78582-26) and submitted by the physician. The facility will report the technical component of the service (i.e., 78582-TC). The facility will also be responsible for reporting any of the radiopharmaceuticals used during the study, as appropriate (e.g., A9558, Xenon Xe-133 gas, diagnostic, per 10 millicuries),” adds Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.