Pulmonology Coding Alert

Code 32491's descriptor eliminates the need to ever use modifiers 50, 52.

Billing for lung volume reduction surgery (LVRS) can reimburse you as much as $1,441 -- but your coding has to be spot-on to guarantee you'll be paid.

Quick Fact: LVRS is sometimes referred to as reduction pneumoplasty (RP). It requires a comprehensive team approach that can only be delivered by an experienced team of thoracic surgeons, pulmonologists, anesthesiologists, and nurses who specialize in complex lung disease.

Flip the situation to your favor by keeping an eye on the following warning signs, and you'll be sure to avoid losing those valued dollars.

Applying Modifier 50 Could Mean Trouble

The code for lung volume reduction is 32491 (Removal of lung, other than total pneumonectomy; excision-plication of emphysematous lung[s] [bullous or non-bullous] for lung volume reduction, sternal split or transthoracic approach, with or without any pleural procedure). The issue of unilateral or bilateral surgery does not apply on 32491 because you should assign 32491, regardless of whether the thoracic surgeon performs the procedure on one lung or two.

Therefore, no more need for modifier 50 (Bilateral procedure) to indicate a bilateral procedure, or modifier 52 (Reduced services) to reflect a unilateral procedure for a code that is considered inherently bilateral.

Pay-up: With a transitioned RVU total of 41.51 and conversion factor of $36.8729, 32491 should give you about $1,530 in reimbursement -- that is, if you billed the procedure appropriately.

Documentation Lacking? Prove Medically Necessity

Many payers cover LVRS, particularly for chronic obstructive pulmonary disease  (COPD, 496) with underlying severe emphysema (492.8, Other emphysema). To be able to show 32491's medical necessity, you should meet some medical guidelines, which varies from payer to payer. Nonetheless, the medical world agrees that a candidate for LVRS should have severe emphysema, disabling dyspnea (786.0x), and evidence of severe air trapping Make sure you meet the following criteria before considering 32491 for your Medicare patients (and those that follow Medicare guidelines). Use information in Section 240.1B.1-3, available at http://www.cms.gov/manuals/downloads/ncd103c1_Part4.pdf.

Documentation hot spot: One way of evaluating patients for LVRS is through a perfusion scan, which determines whether there's a mismatch between the perfusion and the ventilation in the lung. The test sees if there are any parts of the lung that have low perfusion, says Kevin Carney, RN, at Temple University Hospital, Temple Pulmonary Center, Philadelphia. When the physician orders a perfusion scan, the interpreting physician should report 78588-26 (Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, 1 or multiple projections, professional component).

Helpful: Code 78588 represents a combined procedure to determine both pulmonary perfusion and ventilation -- bundling together codes 78580 (Pulmonary perfusion imaging, particulate) and 78586 (Pulmonary ventilation imaging, aerosol; single projection) or 78587 (Pulmonary ventilation imaging, aerosol, multiple projections [eg, anterior, posterior, lateral views]).

Make Sure to Include G Codes

The surgery must be preceded and followed by a program of diagnostic and therapeutic services consistent with those provided in the National Emphysema Treatment Trial (NETT) and designed to maximize the patient's potential to successfully undergo and recover from surgery.

The program must include a 6- to 10-week series of at least 16, and no more than 20,preoperative sessions, each lasting a minimum of 2 hours. It must also include at least 6, and no more than 10, postoperative sessions, each lasting a minimum of 2 hours, within 8 to 9 weeks of the LVRS.

Important: This program must be consistent with the care plan developed by the treating physician following performance of a comprehensive evaluation of the patient's medical, psychosocial and nutritional needs, be consistent with the preoperative and postoperative services provided in the NETT, and arranged, monitored, and performed under the coordination of the facility where the surgery takes place.

The facility reports the following HCPCS codes for preoperative pulmonary rehabilitation and Post-discharge pulmonary surgery services before and after LVRS, respectively based on the number of days in each phase:

• G0302 -- Pre-operative pulmonary surgery services for preparation for LVRS, complete course of services, to include a minimum of 16 days of services;
• G0303 -- Pre-operative pulmonary surgery services for preparation for LVRS, 10 to 15 days of services;
• G0304 -- Pre-operative pulmonary surgery services for preparation for LVRS, 1 to 9 days of services; and
• G0305 -- Post-discharge pulmonary surgery services after LVRS, minimum of 6 days of services.

Standard: A diagnosis code of 492.0 or 492.8 should always accompany these codes if you want your claim hassle-free.