Pulmonology Coding Alert

Question: We have a Pulmonary Critical Care specialist we are billing for. We have a hospice patient who was under treatment for pneumonia, and developed sepsis. The provider performed E&M for this patient for about half an hour, and also inserted a CVP line. How do we code for this scenario? Do we need to append modifier GW?

Maine Subscriber

Answer: You may report J18.9 (Pneumonia, unspecified organism) and A41.9 (Sepsis, unspecified organism) for this patient. As for the services, the provider performed, you may report:

• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)
• 36558 (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older)

Medicare guidelines says if the reason for the encounter does not relate to the terminal illness, then the provider may report modifier GW (Service not related to the hospice patient's terminal condition). If the patient is in the hospice for a condition unrelated to the current problem, then appending modifier GW is correct.  

Note: The diagnosis code of your current problem should differ from the terminal illness diagnosis code (from which patient is suffering) to suggest the problem is different from terminal illness. Also, keep in mind that receiving hospitalized treatments may revoke the patient's hospice enrollment, and it's important to clarify this with the patient and/or family before pursuing care.

You will need modifier 25 (Significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service) on 99291 to differentiate this from the CVP insertion.