Pulmonology Coding Alert

Question: At 11 p.m. Thursday, the pulmonologist admits to observation an established patient complaining of painful respiration and shortness of breath. The pulmonologist conducts a moderate-complexity observation service. On Friday morning, the pulmonologist performs a diagnostic bronchoscopy, and by 7:45 a.m. he discharges the patient home. Can I code the bronchoscopy separately, or is it bundled into the observation code?

Alaska Subscriber

Answer: The diagnostic bronchoscopy is not bundled into the observation code. You should report it separately. Also, because the physician admitted and discharged the patient on different calendar dates, you should report one code for the initial observation care and another code for the discharge. On the claim, report the following services on the following days:

• 99219 (Initial observation care, per day, for the E/M of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the observation

• 786.05 (Shortness of breath) linked to 99219 to represent the patient's breathing trouble

• 786.52 (Painful respiration) linked to 99219 to represent the patient's chest pain.

• 31622 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]) for the bronchoscopy

• 99217 (Observation care discharge day management) for the observation discharge

• modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99217 to show that the observation discharge service and bronchoscopy were separate services

• 786.05 and 786.52 linked to 99217 and 31622 to represent the patient's symptoms.

Although the patient was in observation for only 8 hours and 45 minutes, the encounter spanned two calendar dates. When an encounter spans two dates, regardless of length, you must report the "per day" observation codes.

If the entire encounter had occurred on Thursday, you would have reported 99235 (Observation or inpatient hospital care, for the E/M of a patient including admission and discharge on the same date, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) as the entire E/M service (no separate discharge code).