Pulmonology Coding Alert

An underlying chronic condition may be creating a problem in a body system apart from the obvious. Therefore, you may examine (and be reimbursed for examining) an established patient with a chronic condition for evidence of health problems in other body systems, without considering such examination a screening, even though screening techniques and modalities may be used.

Carol Pohlig, BSN, RN, CPC, at the University of Pennsylvania Department of Medicine in Philadelphia believes, It is wrong to assume that there is nothing else wrong with a patient who is being treated for a chronic condition and that any other system examination is a screening. She says that the presence of a chronic condition, in itself, prohibits defining all tests for other body parts as screenings. Chronic conditions tend to be systemic, she says. They can easily affect other parts of the body.

As an example, Pohlig says that hypertension (401.9, essential hypertension; unspecified) can affect many systems. She says that although technically the patients other systems have not been affected by the illness, this is not the proper understanding of a screening examination. You could say that although the patient doesnt have an illness, hypertension can constrict the veins and the arteries so much that it can cause a decrease in renal perfusion, which can affect kidney output. Therefore, a genitourinary examination is not a screening, but an examination to determine the progression of hypertension. Suppose the physician needs to examine the legs, hands and feet for peripheral vascular problems (such as 443.9, peripheral vascular disease, unspecified) that were caused by hypertension, Pohlig says. This is not a pure screening the way Medicare looks at screening, which is as an absence of illness. She says a better example of screening is a colonoscopy for colorectal cancer (G0105) for the hypertensive patient. In that situation, the physician is examining the gastrointestinal organ systems for a disease that is not present.

Other Body Systems May Be Affected by the Chronic Condition

Performing a comprehensive examination for an established patient with a new chronic illness isnt necessarily screening, either, Pohlig says. I think that separating that from a true screening visit implies that you wouldnt have a diagnosis.

Pohlig says that looking at body systems other than those affected by a chronic systemic disease is simply part of a good clinical evaluation. It makes medical sense, she says. If you dont examine these other parts of the body when looking at the progression of the disease, you could have other medical/legal issues involved. This is not screening in the sense of preventive medicine codes.

Pohlig observes that now, more than any other time, there are more Medicare patients who really dont have any chronic conditions. This (Medicare) generation is taking on a more health-oriented environment and way of looking at things, she says. There are more and more patients in the Medicare population who might not have any chronic conditions. Nowadays, its going to be a little bit more tricky as to when to use each of those separate codes.

Add Modifier -25 for Separate Services

There also are ways to bill for both preventive medicine and an office visit for an established patient. If during the course of a preventive medicine examination the physician discovers an incidental problem for which the patient did not seek treatment, he or she can then treat that problem and bill for the appropriate office visit code (99211-99215) in addition to preventive medicine (99391-99397). Doing so will require using modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the problem-focused evaluation and management (E/M) service.

When youre billing for a preventive medicine service and an office visit, whether it be a new or established patient, you need to apply the -25 modifier to the office visit code, using the problem-oriented diagnosis code to identify the reason for the service, Pohlig says.

Mary Mulholland, RN, BS, CPC, reimbursement analyst at the University of Pennsylvanias Department of Medicine at Philadelphia, says that checking other body systems in a patient with an established condition should be coded as a problem-focused visit. The physician is doing an evaluation to see if the condition has progressed or is stable, or if a change needs to be made in present therapy.

Mulholland says that if in the process of doing a routine general medical examination the physician determines a problem, he or she could bill for both services. You would use the diagnosis general-medicine-exam code, the V70.0 (routine general medical examination at a healthcare facility) and accompany that with the preventive medicine codes, 99381-99397, which are based on whether the patient is new or established, she says. For the problem-focused visit, you would use the diagnosis of the problem the physician discovered, and then bill the level of service the physician provided to treat that particular problem, and use modifier -25 to indicate that its two separate services.

For Example ...

Mulholland uses as an example a male patient over 50 having a screening for prostatic specific antigen (G0103, prostate cancer screening; prostate specific antigen test [PSA], total). You have no idea whether the patient has a disease. In that instance, the screening guidelines are that the patient is over 50 and you were screening for potential prostate carcinoma (185, malignant neoplasm of prostate, excludes: seminal vesicles [187.8]). For a patient diagnosed with hypertension, you wouldnt be screening for that; you would be evaluating to see if there had been a progression of a current disease process.