Pulmonology Coding Alert

Why you may be losing $120 for tube placements You can end the confusion over respiratory acidosis and alkalosis if you know that pulmonologists may insert an endotracheal tube (31500) to clear a patient's airways. By contrast, an alkalosis patient may more likely require either an E/M service or ventilation management, depending on the patient's condition.

Also, you should know the three types of acidosis: acute, chronic, and acute on chronic, says Lewis Taub, MD, a pulmonary specialist at Lovelace Sandia Health System in Albuquerque, N.M. Usually, the different types determine signs and symptoms, and treatment options. (See related story "Tie the Right ICD-9 Codes to Acidosis and Alkalosis Care".) Count Puncture, ABG as Exam If the pulmonologist encounters a possible respiratory acidosis (276.2) or alkalosis (276.3) patient in the hospital, the physician may order an arterial blood gas study (ABG, 82800-82810) to make an official diagnosis.

Example: Your pulmonologist orders an ABG. The hospital's nurse draws a sample of the patient's blood to measure the oxygen and carbon dioxide levels. Because the hospital administered the testing, the hospital bills for the ABG (for example, 82803, Gases, blood, any combination of pH, pCO2, pO2, CO2, HC03 [including calculated 02 saturation]), says Lois Geist, MD, a pulmonologist with the University of Iowa Healthcare's department of internal medicine in Iowa City.

The hospital will also use 36600 (Arterial puncture, withdrawal of blood for diagnosis) for the blood sample.

When your pulmonologist reviews the test results, the physician may include this work in CPT's "amount and complexity of data" category of medical decision-making. But the physician must have provided an E/M service.

For instance, you may report 99222 (Initial hospital care ...) for the physician reviewing and ordering a moderate amount of data, in addition to rendering an evaluation and other care.

Remember: CMS prohibits physicians from charging separately for the interpretation of an ABG, so it's important to count the test review toward the E/M level, if possible.

Get Ready to Code Extensive Treatments When a patient has either acidosis or alkalosis, the physician will treat the underlying cause of the respiratory problem, Taub says.

For instance, a sudden respiratory compromise or failure, such as from chronic obstructive pulmonary disease (COPD, 496, Chronic airway obstruction, not elsewhere classified), often causes chronic respiratory acidosis. Therefore, you may have to report extensive treatments, such as endotracheal tube placement and ventilator management.

Coding scenario: The physician needs to clear the patient's airways. The physician inserts an endotracheal tube and provides ventilator management. For the tube insertion, you should report 31500 (Intubation, endotracheal, emergency procedure), Geist says. If the patient is on Medicare, you can expect about $120 for 31500, depending on your locality and payer.

When you code the [...]