Pulmonology Coding Alert

Patient has pneumonia, too? Use a diagnosis code that extends to the last digit.

You stand to lose your physician’s hard earned dollars if you don’t keep your eyes open for potential stumbling blocks while reporting a claim for cystic fibrosis (CF) treatment.

Answer the following three questions right, and you can rest assured that you are on the failsafe path to avoid unnecessary setbacks in reporting the diagnosis and treatment of CF patients.

CF basics: Cystic fibrosis is an inherited disease that causes the mucus lining the mucosal surfaces of internal organs to become thick, dry, and sticky. This denser mucus (secretions) in the lungs gives bacteria a uniquely favorable place to grow, making CF patients more susceptible to more strains of bacteria than other people.

When your pulmonologist treats patients diagnosed with CF, she will possibly prescribe exercise, antibiotics, bronchodilator therapy, mucolytic therapy, airway-clearing methods/ devices, and chest physical therapy (CPT). CPT, as a treatment, helps to remove the secretions from the lung to the upper airways where it can be coughed out.

1. Is Your CF Diagnosis Code Specific Up to the Last Digit?

When your pulmonologist confirms a CF diagnosis, you should think of the ICD-10 code family E84.0-E84.9.

For example, if your physician sees a CF patient showing pulmonary exacerbation, she will order a direct sputum acid-fast stain and culture for identifying the mycobacteria. Which diagnosis code should you report?

Although the code E84 (Cystic fibrosis) covers the general condition, you should consider going deeper into the family of codes to find a specific code. As many CF patients develop pneumonia, so you should use a cystic fibrosis diagnosis code that extends to the last possible digit of specificity. In this case, you can use E84.0 (Cystic fibrosis with pulmonary manifestations) since the physician clearly stated “pulmonary exacerbation” in the narrative description. “Once the organism has been identified, then an additional code to represent the organism can be reported for any further services,” informs Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.

2. Does Your Physician Service Come With Equipment Ownership for CF Tests?

Your pulmonologist will often be called by hospitals, which own the testing equipment, to evaluate and monitor the pulmonary manifestations of CF for admitted inpatients. The pulmonologists may order pulmonary function tests (PFT), such as spirometry (94010- 94799, Pulmonary diagnostic testing and therapies), chest x-rays (71010, Radiologic examination, chest; single view, frontal) and sputum smears/cultures (88160, Cytopathology, smears, any other source; screening and interpretation), in order to keep a tabs on the patient’s condition throughout the hospital stay. She may also have to coordinate with the primary physician to monitor and analyze the treatment, and to address any further pulmonary problems that may occur.

Watch for: Although a rare scenario, you may be part of a setting where a pulmonologist owns the x-ray equipment used for imaging in the outpatient clinic. If so, you can safely bill for the x-ray using radiologic examination codes (71010- 71035). Otherwise, the pulmonologist will send the patient to an outside facility to get the x-rays done. In that case, you can only report the pulmonologist’s review of the x-ray results into the medical decision-making portion of the E/M service (99201- 99215, Office or other outpatient visit...) provided to the patient. “The facility and the radiologist will report the x-ray services provided to the patient,” Pohlig adds.

Focus on the services: While coding, you should focus on the physician’s services.

The pulmonologist will aim for achieving three main goals when treating CF: slowing lung damage with therapy, improving breathing by loosening and thinning mucus, and preventing or reducing lung infections. On this line, the pulmonologist will most likely go in for these five specific treatments to achieve these goals:

(1) medications, particularly antibiotics, to help manage lung infections;

(2) bronchodilators to help open the airways in the bronchial tree;

(3) mucolytics and inhaled hypertonic saline to help thin mucus;

(4) bronchial alveolar lavage (if needed) (31624, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage) to help clear away excess mucus; and

(5) CPT to assist the patient in clearing secretions (94667, Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation; 94668, Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent).

3. Do You Need to Factor In An External Provider to Perform CPT?

Your pulmonologist may need to employ the CPT service in not just the outpatient clinic but in a variety of settings, including a critical care unit, a hospital room, nursing homes, outpatient clinics, and perhaps in the patient’s home.

What to do: If an external provider, such as a respiratory therapist, nurse, or physical therapist is called in to perform CPT, he/she should not initiate the service unless there is an initial prescription from a pulmonologist. This prescription should identify the patient, list the diagnosis, describe the frequency of visits, and define the duration of the treatment regimen.

Make sure you meet the following guidelines to justify CPT treatment by a registered provider:

• There is a documented treatment plan to stabilize the patient's status.
• The patient's pulmonary condition is unstable.
• caregiver, such as a family member, can commit to performing CPT on the patient on a regular basis (for example, parents working full time or patient living alone).

Example: A CF patient is given a prescription to receive CPT in the home. Initially, a pulmonologist, nurse, or respiratory therapist will explain and demonstrate techniques such as breathing control, percussion, and vibration techniques. The patient or his caregiver performs the therapy under the health professional’s observation to be sure it can be done correctly. You should report this initial evaluation and demonstration with code 94667.

When manual manipulation of the chest wall by means such as cupping, percussing, and vibration is not enough to improve a patient’s lung function, the provider may perform a mechanical manipulation. For example, the provider may use a high frequency chest wall oscillator, or HFCWO, apparatus, which may look like a vest. This apparatus includes a band that is placed around the person’s chest and a drive that is connected to the chest band. The drive varies the circumference of the chest band in cycles, applying an oscillating compressive force. If you are reporting a mechanical oscillation, you should report 94669 (Mechanical chest wall oscillation to facilitate lung function, per session). “Be sure to check payer policy as 94669 may have specific coverage criteria and limitations for use,” Pohlig cautions.

Watch this: You should not report the use of a device such as a mechanical percussor or high-frequency compression device such as the VEST as 94667 since the code is reserved for demonstration of techniques used for treatment and the device can only be covered as Durable Medical Equipment (DME), Instead, use the HCPCS code E0480 (Percussor, electric or pneumatic, home model), which would be report to DMERCs and not to Part B Contractors.

On the other hand, if your practice employs the CPT provider, you can bill your CPT provider’s subsequent visit to a patient’s home with 94668. Also, if a bronchodilator is administered by the provider, you can bill 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]).

Quick fact: If a home health-employed physical therapist administered CPT, the home-health agency reports different codes: G0151 (Services performed by a qualified physical therapist in home health or hospice setting, each 15 minutes), and S9131 (Physical therapy; in the home, per diem).