Pulmonology Coding Alert

Hint: Get acquainted with your carriers' LCDs

One of the biggest challenges coders face is deciphering individual carrier guidelines on how to code procedures and services. Review these expert tips that will keep you organized so you can choose the right pulmonology code and modifier regardless of payer differences.
 
Here's how to keep straight who wants what.

1. Chart Those Choices

Best bet: Set up a spreadsheet to keep track of frequently applicable payer policies and quirky filing requirements. In this spreadsheet, you should also note which codes each payer accepts for common procedures, which codes they never accept, which diagnosis codes they allow for each procedure code, which modifiers the payer allows, and how you should report them. Keeping a spreadsheet means that you've got who wants what already ironed out.
 
"We have a notebook divided by payer with specifics for each. We use this information for discussions with providers," says Nancy Lynn Reading, RN, BS, CPC, a coding educator with University Medical Billing at the University of Utah in Draper.
 
Example: You may have one payer that wants you to place "2" in the units box if you use modifier 50 (Bilateral procedure) and another that wants you to place "1" in the units box for that modifier, so you should make sure this information is at hand in your spreadsheet.

2. Don't Let Your Guard Down

To stay current on your payers' policies, you have to dig through their newsletters and Web sites. Because CMS has made a point of going paperless, you have to be doubly vigilant in checking for Medicare and Medicaid online bulletins.
 
Good practice: "I check our major local and national payers' as well as Medicare's newsletters and policies the first week of every month," says Anne Karl, RHIA, CCS-P, CPC, coding and compliance specialist at St. Paul Heart Clinic in Mendota Heights, Minn. "It's very beneficial to keep up on what new edits may be coming."
 
What to do: If your patient is covered by TrailBlazer Health in Texas, and you go to this Medicare carrier's Web site (www.trailblazerhealth.com), in the center of the page you'll see a "What's New" column to help you keep up with the latest information.
 
If you have a question about a specific policy, click on "Texas" under "Part B" on the left side of the screen. Then to find a policy for a particular procedure, click on "LCD (Local Coverage Determination)" in the left column. You can search by the name of the procedure or the CPT code.
 
Example: You have a report of a patient with documented asthma and shortness of breath, and the pulmonologist wants the patient to undergo spirometry testing before and after bronchodilator. You want to make sure the TrailBlazer policy states the diagnosis code that proves medical necessity for this service. You know the procedure code is 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration).
 
1. Type 94060 into the search field on the TrailBlazer Web page. This will bring up links to the LCDs for this code. In this case, there is only one, and when you click on that link you'll see the LCD, "Pulmonary Function Testing."
 
2. Scroll down past the explanation of the procedures, and you'll see lists of exactly which CPT codes you may use to report this service (which, in this case, includes 94060) and lists of which diagnosis codes prove medical necessity. Codes 493.90 (Asthma, unspecified; unspecified) and 786.05 (Shortness of breath) are on the list, so you can trust that you are reporting a code combination that TrailBlazer will pay.

3. Analyze Denials and Payments for Clues

You can seize many benefits by taking the time to clarify and summarize payer policies. Analyze payments and investigate those that appear too low before they add up too much, experts say.
 
You'll thrive over time if you're willing to learn from your denials. If a payer consistently denies a specific code, you should thoroughly investigate it, identify what triggered the denial, and implement corrective actions to prevent it from happening again. Don't automatically appeal or write off every denial, Reading says. "You need to determine if you coded properly and had the correct documentation up-front and then determine if the denial has merit."

4. Network, Network, Network

For many coders, listservs are a lifesaver. They give you the chance to get answers from others in your specialty and experts in the field. Look for the specialty lists offered online by The Coding Institute at www.coding911.com. You can sign up for our pulmonology discussion group and access the questions and answers from past discussions.
 
When you have a question about a payer's policy, you can post your query to the list to hear from others who have dealt with the same situation.
 
If another coder provides you with official documentation to solve your problem, you've saved yourself about 45 minutes of waiting for your payer's customer service to take your call. And even if you don't get an official answer, you're now armed with information to help you decide if the payer representative who answers your call is giving you an answer you can trust.