Pulmonology Coding Alert

Question: We admitted a 90-year-old Medicare patient with pulmonary infiltrate (pneumonitis) and performed a bronchoscopy the next day. Later that night, the pulmonologist had to visit the patient for dyspnea (786.09), hypoxemia (799.0) and severe coughing after he vomited and likely aspirated. The physician was at the patients bedside for one hour while he was critical. How should we code this?

Rick Scacewater, MD
Joplin, Mo.

Answer: For the bronchoscopy, you should use 31622 (bronchoscopy [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]). For the critical care visit later the same day, use 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

An ICD-9 code different from the one used for the bronchoscopy should be used for the critical care service. This will convey to the insurer that the two services are separately identifiable. In the above example, pulmonary infiltrate (518.3) can be reported with the 31622. And hypoxemia (799.0) and dyspnea (786.09) can be reported with the critical care service.

If the physician cannot generate separately identifiable ICD-9 codes for each of the services provided, you should attach modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99291 to show that it was a separate service from the bronchoscopy. The carrier should pay for both services for the day, but it may require a review of the documentation before payment. Make sure your documentation clearly defines the patients condition and that you have included the time to verify the amount billed as critical care.

This reader question was answered by Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., and Carol Pohlig, CPC, RN, a reimbursement analyst for the office of clinical documentation, Department of Medicine at the University of Pennsylvania in Philadelphia.