Pulmonology Coding Alert

Read the medical note and determine which codes you would report.

Sometimes it can be challenging to determine the right codes for an inpatient encounter unless you have all of the documentation in front of you. This month, we’re challenging our readers to review the notes from a respiratory distress encounter. Afterward, determine whether you know which the right codes are for the visit.

First, Read This Note

Your first step in getting to the bottom of this encounter is to read the following note:

This 56-year-old patient underwent coronary artery bypass surgery, after which he had difficulty ventilating in the recovery room. The pulmonologist was called for an urgent status consult but was unable to obtain a complete history because the patient was sedated.

Past History: According to his chart, the patient has a history of hypertension, diabetes, congestive heart failure, Charcot-Marie-Tooth disease, nephritic syndrome, and obesity.

Physical Exam: The patient is morbidly obese. When the pulmonologist saw the patient, he was not in distress. He was well sedated and on a ventilator. His vital signs showed a temperature of 100, pulse 103, respiratory rate 17, blood pressure 117/49, CPAP 11, pulmonary artery wedge pressure 15, pulse oximetry was going down into around the mid-80s, and now after adjustment of the endotracheal tube, pulse oximetry has gone up to 92 percent.

The chest exam showed diminished breath sounds on the left and somewhat diminished sounds on the right side. The pulmonologist notes that the breath sounds were more diminished on the left side than the right side. The pulmonologist also noted rales and diminished air movement on the left side.

The patient’s Doppler was negative for deep venous thrombosis (DVT). The pulmonologist reviewed the chest X-ray and showed significant volume loss on the left side and questionable congestion on the right side.

It was difficult for the pulmonologist to identify an endotracheal tube position on the repeat X-ray. The most recent labs showed sodium 140, potassium 4.6, chloride 105, bicarb 24, BUN 56, creatinine 6.5, glucose 101, white cell count 13.0, hemoglobin 9.5, platelets 156. His last set of arterial blood gases (ABGs) showed a ph of 7.33, pCO2 of 41, p02 of 76, bicarb of 31, and saturation 95 percent.

Assessment: Acute hypoxemia post-coronary artery bypass surgery likely related to either mucus plug or malpositioning of the endotracheal tube.

Plan: The anesthesiologist had a difficult time finding the carina during a bronchoscopy. Then the pulmonologist tried a bronchoscopy with a small bronchoscope. Once again, the pulmonologist could not see the carina and he also noted that it was difficult to go through the center of the endotracheal tube because there was hardly any space there.

The pulmonologist pulled out the tube by a couple of centimeters. He then pushed the bronchoscopy tube between the tracheal wall and the end of the tracheal tube. At that time, the patient’s oxygen improved. Finally, the pulmonologist noted a mucus plug that was almost completely occluding the left main bronchus and it was sitting on the carina, which made it nearly impossible to see the carina and the left main bronchus.

The pulmonologist went deeper down the main right bronchus, but once again, because of a small mucus plug, the pulmonologist could not visualize the subsegments.

Results: The pulmonologist’s diagnosis included complete left lung collapse from a large mucus plug and also some kinking of the endotracheal tube against the tracheal wall. After the pulmonologist adjusted the endotracheal tube and removed part of the mucus plug, the patient’s oxygen improved to 92 percent.

Plan: At this time, the pulmonologist is waiting for a larger bronchoscope, which he will use to suction out the mucus plug completely.

Can You Code This Case?

The documentation notes that the pulmonologist performed an urgent inpatient consultation. Therefore, it’s likely that you’ll report 99255 (Inpatient consultation for a new or established patient ...), considering the complexity of the case, the amount of data the pulmonologist reviewed, and the level of high-complexity decision-making. However, this code only applies if the patient’s insurer still recognizes the consultation codes. Many private insurers will reimburse for them, but since Medicare does not, some other payers have adopted a non-payment policy on them as well.

In addition to high-complexity decision-making, the pulmonologist also needs to obtain and document a comprehensive history and exam. Without any of these criteria, you cannot report 99255.

Don’t forget: You should also append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99255 because the pulmonologist provided the consult in addition to the bronchoscopy.

The pulmonologist performed a diagnostic bronchoscopy, for which you should report 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)). Therefore, your coding report should include 99255-25 and 31622.

Extra: If the pulmonologist performs a second bronchoscopy to remove the mucus plugging, you should report a therapeutic bronchoscopy (31645, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial).

If they performed the second bronchoscopy on the same day, you should add modifier 59 (Distinct procedural service) to notify the payer that the pulmonologist performed a distinct service separate from the diagnostic bronchoscopy. “You will likely be denied for the diagnostic bronchoscopy (31622) since the National Correct Coding Initiative (NCCI) fatally bundles them (no ability to override the edit with a modifier),” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. “You can try to appeal with the notes and the procedure reports to support the rationale behind the separate sessions. However, the payer may uphold the denial.”

Don’t forget: You should report diagnostic code J96.01 (Acute respiratory failure with hypoxia) for the initial respiratory failure the patient suffered.

Also report J98.11 (Atelectasis) and I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris) for the other conditions contributing to the patient’s current physical condition.