Pulmonology Coding Alert

Plus: Check out these potential changes to E/M documentation, lung tumor ablation codes.

Pulmonology coders may not be ready for 2018 yet, but CMS is already prepping for the calendar to turn, releasing the 2018 proposed Medicare Physician Fee Schedule, which recommends updates to the Part B payment policy. The proposals could be significant for lung care practices, since some of the biggest revisions involve completely overhauling how E/M codes are selected, and the proposal also reveals changes to chest x-rays, pulmonary diagnostic testing and pulmonary tumor ablation codes.

Potential E/M Documentation Changes

The proposed rule indicates that CMS is looking at updating the E/M code requirements for the first time in decades. "We are specifically seeking comment on how we might focus on initial changes to the guidelines for the history and physical exam because we believe documentation for these elements may be more significantly outdated, and that differences in medical decision-making (MDM) are likely the most important factors in distinctions between visits of different levels," CMS says on page 377 of the proposal.

CMS is not only suggesting that it might lean more heavily on MDM when selecting an E/M level, but even appears to be considering eliminating history and physical exam documentation requirements entirely. "We are also specifically seeking comment on whether it would be appropriate to remove our documentation requirements for the history and physical exam for all E/M visits at all levels," the proposal says. "We believe medical decision-making and time are the more significant factors in distinguishing visit levels, and that the need for extended histories and exams is being replaced by population based screening and intervention, at least for some specialties."

Strong MDM, Time Components Could Benefit Pulmonary Practices

CMS' proposal may be shocking to many in the coding industry, but could have many positive impacts if finalized. The proposal that time would be more important in selecting an E/M code could be helpful in some cases, said Catherine du Toit, CPC, CPMA, CGIC of Clean Claims Coding Consultants.

Because pulmonary practices frequently see patients with complex medical diagnoses, the MDM is often the most high-level part of the visit. In addition, many lung specialists spend a significant amount of time speaking with patients and their families about treatment options and prognosis issues for conditions like COPD and cystic fibrosis, meaning that E/M code levels are often selected based on time as the controlling factor. If CMS makes it easier to code based on time, pulmonary practices could find code selection faster and easier.

Submit Comments to Have Your Say

Although some practices are cheering the lower documentation burden that this could create, others are questioning why CMS would loosen the requirements for an area of coding that already has challenges. "Removing the history and physical (H&P) component from coding guidelines is like having a tree with no 'roots,'" suggests Vinod Gidwani, president of full-service revenue cycle firm Currence, based in Skokie, Illinois. "The H&P determines the level of medical decision-making as well as the time component. Removing the H&P is like determining the MDM and time components in a vacuum," Gidwani says.

No matter where you stand on this issue, CMS wants to hear from you. "We are seeking comment on whether clinicians and other stakeholders believe removing the documentation requirements for the history and physical exam would be a good approach," the agency says in the proposal.

If your practice has an opinion on this matter, now is a good time to submit your comments, which are due by Sept. 11, 2017. You can either submit online at www.regulations.gov (referencing CMS-1676-P), or by mail or in person.

Could Chest X-Ray Codes Be Set for a Big Change?

The fee schedule proposal lists four new chest x-ray codes that appear to be slated for a Jan. 1 debut, and assigns RVUs to them. Although the fee schedule doesn't reveal the exact CPT^® code assigned to the new assignment, the following details are shared in the proposal:

• 710X1: Radiologic examination, chest; single view
• 710X2: Radiologic examination, chest; 2 views
• 710X3: Radiologic examination, chest; 3 views
• 710X4: Radiologic examination, chest; 4 or more views

Although the fee schedule proposal doesn't indicate whether there is a plan in place to delete existing chest x-ray codes that are similar to the above proposed codes, chances are that there will be big changes in chest x-ray coding going forward. For example, code 71030 (Radiologic examination, chest, complete, minimum of 4 views) has a very similar descriptor to the new proposed code 710X4 and carries the same work RVUs (0.31), so it's highly likely that the new code will replace the existing one.

Pulmonary Diagnostic Testing Codes Could Change

The proposal also suggests that CPT will be deleting 94620 (Pulmonary stress testing; simple [e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry]) after it was "identified as part of a screen of high expenditure services," CMS says. CPT will introduce the following two codes that will replace 94620, the proposal indicates:

• 946X2: Exercise test for bronchospasm, including pre- and post-spirometry and pulse oximetry
• 946X3: Pulmonary stress testing (e.g., 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed

The proposal separates each of the services that were previously described by 94620 into two separate codes so they can each be valued differently.

Updated Pulmonary Tumor Ablation Codes Revealed

The proposal also lists suggested relative value units (RVUs) for a new pulmonary tumor cryoablation code and a revision to an existing code in that category that appear to be slated for a Jan. 1, 2018 update, as follows:

• Revised code: 32998: Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral, radiofre­quency (revised verbiage is in bold)  
• New code: 32X99: Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation.

In the past, coders had to report Category III code 0340T (Ablation, pulmonary tumor[s], including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance) for cryoablation of pulmonary tumors, so the above new codes will definitely come in handy for lung care practices if finalized.

CPT^® 2018 should be revealed within the next few months, so keep an eye on Pulmonology Coding Alert to find out exactly how these codes will be updated as the details come to light.

Resource: To read the proposed fee schedule, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-14639.pdf.