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Pulmonology Coding Alert

Reporting E/M Visits and Thoracenteses:

Modifier -25 Can Help

Published on Fri Jan 02, 2004

Separately bill office visits that go beyond the surgical procedure

If you know how to use modifier -25, you might be able to report an E/M service in addition to your pulmonologist's thoracentesis procedures.
 
CPT 2004 deleted the starred designation from 32000 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent), which makes reporting the code more consistent with insurer guidelines. When the procedure had a star, that meant a global package did not apply to the procedure.
 
But remember that you should not bill for an E/M service if the pulmonologist didn't perform an evaluation beyond what the thoracentesis procedure includes. For example, prior to performing the procedure, the physician should evaluate the patient to determine the most appropriate needle insertion location. Once the physician completes the thoracentesis, the physician re-evaluates the site and provides care to prevent complications that could result from the surgery.
 
You could not report an E/M code for the pulmonologist's work, because the physician examined the patient for conditions related to the surgery. If you want to report an E/M visit in addition to the thoracentesis, make sure your physician performed an office visit separate from the procedure. Typically, the pulmonologist evaluates a patient's condition before performing a thoracentesis.
 
For example, a patient's primary-care physician (PCP) requests that your pulmonologist examine a patient. Following the exam, your physician decides to perform diagnostic thoracentesis (32000) for fluid removal.
 
In addition to reporting 32000, you could also assign an office consult code, such as 99244, for the evaluation. If you append modifier -25 (Significant, separately identifiable evaluation and management service by the
same physician on the same day of the procedure or other service) to 99244, you'll let Medicare know that the physician performed the E/M service separately from the thoracentesis. If you're reporting to a private payer, check the billing policy to make sure the insurer allows you to use modifier -25.
 
Remember that CPT doesn't require you to provide different ICD-9 codes for the E/M service and thoracentesis procedure, but you should use different diagnosis codes when possible. Using different diagnosis codes provides clear medical justification for the E/M service and procedure. Therefore, you improve your chances of the insurer paying you for the E/M, says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia.
 
For instance, a patient complains of painful respiration (786.52) and wheezing (786.07), and your pulmonologist admits the patient to the hospital. X-rays reveal pleural effusion (511.9). Then your physician performs diagnostic thoracentesis to establish a specific diagnosis. You could code this scenario as follows:
 
  •  99223-25 - Initial hospital care, per day...; significant, separately identifiable evaluation and management service by the same physician ...
     
  •  32000 - Thoracentesis...
     
  •  Link ICD-9 codes 786.52 and 786.07 to 99233, and link 511.9 (Unspecified pleural effusion) to 32000. You should use 511.9 as the diagnosis code unless the physician provides a more specific diagnosis, such as 511.1 (Pleurisy; with effusion, with mention of a bacterial cause other than tuberculosis).


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