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 first day of ventilator management, you may use 94656 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day). Because you're submitting 94656 in a facility setting, you can expect Medicare to pay about $60.

If the physician administers ventilator management on following days, you should report 94657 (... subsequent days), which Medicare reimburses at an average of $40.

Tip: You may be able to bill for critical care services (99291-99292) because acidosis patients usually meet the critical care definition, Taub says.

The following example illustrates how you can report critical care codes when the physician treats acidosis patients.

Example: The pulmonologist treats an unconscious COPD patient with acute respiratory failure (518.81). After an ABG study reveals acidosis, the physician inserts an endotracheal tube and places the patient on a ventilator. Because the patient is critically ill, the physician manages the patient's condition for 45 minutes.

As long as the documentation supports the patient's critical condition, the physician's management, and the time the physician spent providing the service, you can  report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), coding experts say.

Medicare pays about $150 more for 99291 than for 94656-94657 because critical care requires more extensive service than ventilator management.

Warning: You should not assign 94656-94657 (ventilator management) if you are reporting critical care codes (99291-99292) as well. CPT specifically includes ventilator management with critical care, pulmonology coding experts say.

In addition, the National Correct Coding Initiative edits bundle 94656-94657 into all E/M codes.

Use E/M Codes for Alkalosis Care

Patients may develop alkalosis while already on a ventilator in the intensive care unit. The kind of treatment and the codes you use will depend on the patient's underlying condition.

How it works: A patient on a ventilator in the intensive care unit develops alkalosis because he's not breathing above the rate the physician set. The physician decreases the breathing rate or tidal volume.

Coding advice: You should include the physician's work in the ventilation management services (94656-94657), or possibly critical care (99291-99292), depending on documentation.