Pulmonology Coding Alert

Question: The pulmonologist placed a patient on antibiotic therapy to treat an upper respiratory infection. The next day, the patient complained that the medication caused her severe epigastric discomfort. The physician changed the medication, which the patient tolerated. How can the pulmonologist receive payment for two services in one week?

Tennessee Subscriber  

Answer: The pulmonologist must prove medical necessity for each service. When the patient presents to the physician or nonphysician practitioner (NPP) with symptoms of an upper respiratory infection in the first service, the provider should choose diagnosis codes to match the patients condition. For example, the patient may have a cough (786.2), sore throat (462), and fever of a nonspecific origin (780.6). The pulmonologist may determine that this cluster of symptoms is consistent with an upper respiratory infection (465.9). When submitting diagnosis codes for any visit, the physician may list up to four. In this case, he or she should submit all of the above codes to paint an accurate clinical picture.
 
When the patient returns to the office complaining of epigastric pain, that visit represents an adverse reaction to the prescribed medication. The situation is a good example of when to use E codes, which describe circumstances that caused the injury, not the nature of the injury.
 
Because the patient followed the providers treatment and took the antibiotics as recommended, you should code epigastric pain (789.06) as the first diagnosis. If the provider determines that the symptom(s) are related to the therapeutic use of the antibiotic, the provider should use the appropriate E code to identify the drug (for example, if the patient takes erythromycin, report E930.3).