Pulmonology Coding Alert

Pulmonary physicians who see skilled nursing facility (SNF) residents in the office face tricky coding and billing scenarios. Because the Balanced Budget Act of 1997 requires SNFs to "consolidate" their billing for Medicare Part A-stay residents, all but a few services are excluded from the prospective payment system (PPS). Physicians who bill Medicare for services that are part of the all-inclusive PPS rate could be setting themselves up for payment recoupments and potential fraud and abuse investigations.
 
The first step in consolidated billing is to develop a "tickler system" or other mechanism to identify Part A SNF-stay patients seen in the office. "Many SNFs send a form or notice to the physician's office with the Part A-stay patient instructing the physician's office to bill the SNF for services subject to consolidated billing," says Rusti Bauman, RN, a nursing and reimbursement consultant with FD&R Healthcare Consulting in Deerfield, Ill.   
Consolidated Billing Scenario
The following example illustrates how to code for an SNF patient seen in the pulmonologist's office:
 
A 68-year-old Medicare beneficiary who has been followed by the pulmonologist for emphysema (492.8) presents to the office for evaluation of increasing episodes of wheezing. The pulmonologist is aware that the patient is receiving a short course of inpatient Part A skilled nursing facility care following a three-day hospitalization for uncontrolled diabetes mellitus (250.03) and influenza with pneumonia (487.0).
 
The doctor orders his office staff to perform a chestx-ray and a finger stick to obtain a white blood cell count, both of which are read as normal. He performs a focused exam, noting obvious wheezing upon chest auscultation. The pulmonologist asks the nurse to administer a nebulizer treatment for acute airway obstruction (94640). The patient's color improves following the treatment.
 
The pulmonologist calls the SNF geriatrician to provide an update on the patient's worsening asthma and suggests nebulizer treatments be provided in the SNF for wheezing episodes. The pulmonary physician bills the SNF for the following services:

  The technical component of the x-ray (71010-71035) if he or she owned the equipment
  The lab test if he or she analyzed the specimen, with modifier -TC (Technical component) appended to the appropriate code 
  The nebulizer treatment (94640), which is considered respiratory therapy and covered by the SNF PPS. No modifier is needed.
 
The pulmonologist bills the E/M services for the office visit to the carrier using 99213 (Established patient with two of three key components and low to moderate severity of presenting problem with 15 minutes typically spent face-to-face with the patient). The ICD-9 code for the visit is obstructive bronchitis, acute exacerbation (491.21).
Sleep Studies, Function Tests and Bronchoscopy
 
 
The technical component of sleep studies and pulmonary function testing is also included in the SNF [...]