Pulmonology Coding Alert

Pulmonologists treating patients for asthma may assign codes from several sections of CPT depending on the specific diagnostic and therapeutic services provided. To optimize reimbursement, professionals must understand coding conventions governing relevant procedure codes, as well as the intricacies of reporting the medical necessity of the E/M services.

According to Donald Aaronson, MD, a specialist in asthma and allergies practicing in Chicago, physicians perform a variety of pulmonary function tests (PFTs) to establish a diagnosis of asthma. "Typically, a patient presents with symptoms like chronic cough (786.2), wheezing (786.07) or shortness of breath (786.05). The pulmonologist administers appropriate PFTs to determine the cause of the condition."
 
In most cases, he says, the pulmonologist conducts a baseline evaluation using spirometry. If the results indicate asthma, the physician administers a bronchodilator to relax the bronchial tubes and retests the patient's pulmonary function to determine if the medication improves breathing. This three-step procedure is reported with 94060 (bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]).
 
The reference to 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) within the code description indicates that baseline spirometry before bronchodilation is included in 94060. Both Medicare and CPT consider 94010 bundled into 94060.
 
In some cases, results from the baseline spirometry are normal, and, Aaronson says, the pulmonologist may conduct a methacholine challenge test to pinpoint the diagnosis for the patient's breathing disorder. The administration of this test is described with 95070 (inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds]). And, you should report 94070 (prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics) to describe the PFT that measures the impact of the methacholine.
 
Under these circumstances, it is appropriate to report the initial spirometry (94010) appended with modifier -59 (distinct procedural service). This has been a point of confusion when submitting Medicare claims because the national Correct Coding Initiative (CCI) bundles 94010 into 94070. However, a memorandum from Niles Rosen, MD, medical director for CCI, confirms that it is appropriate to bill 94010-59 on the same day as 94070 if normal results from spirometry are the reason for the subsequent methacholine test. Commercial payers also may allow pulmonologists to report 94010 with 94070.

Once a diagnosis of asthma has been confirmed (493.00-493.91), the pulmonologist will choose from several treatment options. Occasionally, a pulmonologist conducts tests to determine which substances the patient is allergic to. "With this information, we instruct patients on how to control their environment, if possible, and minimize allergic reactions that may trigger their asthma," Aaronson says.
 
Allergy testing is described with codes 95004 (percutaneous test [scratch, puncture, prick] with allergenic extracts, immediate type reaction, specify number of tests) or 95024 (intracutaneous [intradermal] tests with allergenic extracts, immediate type reaction, specify number of tests). Intradermal testing is usually performed during the same visit if no reactions were observed in the percutaneous tests. When this occurs, both 95004 and 95024 may be reported. No CCI edit affects these codes, so no modifier is needed.
 
Note: Although additional skin tests might be performed, Aaronson says an allergist, rather than a pulmonologist, would conduct them. And, an allergist would provide allergy immunotherapy or desensitization services, i.e., allergy shots.

When an asthma patient presents to the pulmonologist's office with an acute flare-up, he or she may receive a nebulizer treatment to relieve the attack. Coders reviewing the CPT manual may be puzzled over which code to assign, since several codes describe similar services. Codes 94640 (nonpressurized inhalation treatment for acute airway obstruction), 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) and 94665 (... subsequent) most often confuse coders.
 
"When a patient suffers from an acute airway obstruction, you should assign 94640," Aaronson says. If symptoms aren't relieved, the treatment may be repeated during the visit. Code 94640 may be reported multiple times, with modifier -76 (repeat procedure by same physician) appended to each subsequent code. In addition to the service code, pulmonology practices may report medications and supplies.
 
In some cases, the pulmonologist administers adrenaline to relieve the patient's symptoms. This is reported with an injection code, 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular), and a Level II HCPCS code describing the substance injected, e.g., J0170 (injection, adrenaline, epinephrine, up to 1-ml ampule). Code 90782 is not payable when reported with another reimbursable service on the same date. If the injection is provided on the same day as an office visit, for example, the physician would submit only a claim for the office visit and the drug.
 
Code 94664, on the other hand, is assigned for evaluations (i.e., a diagnostic test) or patient education about how to use a metered-dose inhaler or nebulizer.
 
When 94664 is used for diagnostic purposes, the patient receives nebulized medication to help produce a sputum specimen. For instance, a 70-year-old woman has difficulty breathing but is not suffering from asthma. The pulmonologist needs to determine what is causing her symptoms. The patient inhales a medication to bring up sputum, which is tested for bacteria or evaluated for viscosity, color or smell.
 
This code may also be assigned when the pulmonologist or a staff member demonstrates proper use of the therapeutic inhaler. Code 94665 would be used for subsequent demonstrations or training at a later date. This might occur if the patient is having trouble with the inhaler or is using it improperly.
 
Both 94640 and 94664 may be reported on the same date of service. Although CCI bundles 94664 into comprehensive code 94640, unbundling is appropriate if the two services are performed for distinct reasons. For instance, a teen-age boy is instructed about using the inhaler and self-administers a dose during the education session. But his symptoms aren't relieved, and a second treatment is given 45 minutes later. Or the pulmonologist may treat an acute attack and subsequently provide training on a metered-dose inhaler. Both 94640 and 94664 may be reported in these cases, and coders should attach modifier -59 to the second code.

Reporting the Office Visit

When patients visit the pulmonologist for assessment of respiratory symptoms, and studies such as PFTs are subsequently performed, the appropriate E/M codes may be reported in addition to the procedure code. Aaronson says separate E/M services must be provided and documentation must indicate they are medically necessary.  

Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) would identify the E/M performed on the same day. 
 
Sometimes, a code from the series for office or other outpatient visits is assigned, e.g., 99201-99205 (new patient). But other times a consultation code is more appropriate, 99241-99245 (office consultation for a new or established patient).
 
To ensure you use these codes correctly, you must know the difference between a consultation and a referral, says Deepa Malhotra, MS, CPC, director of coding and compliance for Healthcare Information Services Ltd. in Willowbrook, Ill., which provides billing services to more than 200 physicians in the Chicago area. A consultation occurs when one physician requests an opinion or advice from another physician regarding a specific aspect of patient care. Once the opinion is communicated, the requesting physician provides treatment and routine management of the medical condition. On the other hand, she says, a referral entails a transfer of the patient's ongoing care to another doctor.
 
To qualify as a consultation, a requesting physician must specifically ask that the pulmonologist examine the patient, perform any necessary tests and provide an opinion about the patient's condition. "The request for the consultation does not need to be in writing, but should be documented in the patient record," Aaronson says. "However, the consultant must send a written report with findings back to the requesting physician."
 
The distinction between a consultation and referral is important because consultations earn more reimbursement  than a regular office visit, which would be reported for a referral, Malhotra says. For instance, 99205 has been assigned 2.67 work relative value units (RVUs), while 99245 has 3.43 work RVUs.
 
Practices often have problems getting paid for a consultation simply because they inadvertently use the term "referral," she adds. "Too often, the requesting physician says he is sending the patient for a 'referral.' When payers spot this word, they assume care has been transferred and will not pay for a consultation."
 
Likewise, the consulting pulmonologist should avoid thanking the requesting physician for a "referral" when supplying his or her opinion, e.g., "Thank you for referring Mr. Brown to me." To support the fact that the visit was a consultation, Malhotra suggests that the pulmonologist use phrases such as "Thank you for asking me to evaluate Mr. Brown for his respiratory condition."
 
Aaronson says it is appropriate for a consultation to include the initiation of treatment. For instance, if asthma is diagnosed, the pulmonologist may provide nebulizer therapy, prescribe a metered-dose inhaler and give appropriate education. "Routine follow-up care is then usually conducted by the requesting physician."
 
Sometimes, however, medical indications require the pulmonologist to supervise treatment. If the transfer of care occurs after the specialist has seen the patient and provided an opinion, the pulmonologist would report a consultation code for the initial evaluation, and outpatient codes for subsequent visits.