Pulmonology Coding Alert

$$$ can fly out the door if ICD-9 overlap afflicts claim.

Getting the most accurate ICD-9 codes possible for your pulmonologists services will go a long way toward preventing denials when coding for concurrent care.Follow this case study and learn how to ensure that everyone is getting paid for their services.

Remember Consult Exception

When your pulmonologist provides concurrent care with other specialists for a patient, you must be sure that each physician is treating a separate patient problem. Otherwise, only one physician will get paid, even if each physicians service is medically necessary.

Confusion surrounding concurrent care can start when the pulmonologist is treating a hospital inpatient and calls in other physicians for consultation. Consider this example from Jill M. Young, CPC, CEDC, CPC-IM, with Young Medical Consulting LLC in East Lansing, Mich:

The pulmonologist is treating a patient with viral pneumonia in the hospital. On Tuesday morning, the pulmonologist checks on the patient during his rounds.The patient complains of coughing up pink mucus.Suspecting possible heart failure, the pulmonologist calls in a cardiologist for consultation.

Both physicians can code for their services with a primary diagnosis of abnormal sputum (786.4) because they were both treating that condition. The pulmonologist would choose a subsequent hospital care code (99231-99233), and the cardiologist would choose an inpatient consult code (99251-99255). Both claims are valid because one of the services was a consult. The exception to the one diagnosis per doctor, per day is the consult, Young says.

Alternatively, since the pulmonologist selects the diagnosis code for the primary condition she is treating, she can also choose to report viral pneumonia (480.9,Viral pneumonia, unspecified) as her primary diagnosis.

The problems can arise the next day, when more than one physician tries to bill for hospital care.

Same Diagnosis Creates Claim Race

The above example becomes a concurrent care scenario Wednesday morning, when tests confirm that the patient is in heart failure. The pulmonologist decides to call the cardiologist to take over care for the patients heart failure. The pulmonologist, however, continues to see the patient for management of his pneumonia. Notes indicate that the pulmonologist provided level-two care.

It is vital that each physician provide diagnosis codes to explain the exact patient problem he is treating. If the pulmonologist does not indicate that he is treating the patients pneumonia and the cardiologist does not indicate he is treating the heart failure, someone is not going to get paid, Young says.

Problem: If two physicians bill for the same conditionon a patient they are concurrently treating, one of them may lose the race to get paid for the claim. In this case receiving payment for your services can be difficult and you may have to navigate through an appeal process.

Solution: You can code the patients condition completely, but be sure that you place your ICD-9 codes in proper order, says Catherine Brink, CMM, CPC, CMSCS, president of Healthcare Resource Management in Spring Lake, N.J.

So the pulmonologist should report his hospital care code with 480.9 appended as a primary diagnosis and 428.0 (Congestive heart failure, unspecified) as a secondary diagnosis.

The cardiologist should report 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) with 428.0 as primary and 480.9 as secondary diagnosis.

Tip: You may report both conditions only if the physicians documentation addresses each issue. The daily note should support the diagnoses the physician selected and reported for each encounter, advises Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Following this advice will ensure that both practices get paid -- and that youve painted a complete picture of the patients condition.

Coordinate With Other Offices to Avoid Overlap

When coding for concurrent care, its the overlap of diagnosis that causes the most problems, explains Quinten A. Buechner, MS, MDiv, CPC, ACS-FP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. Combat this problem with solid encounter notes indicating each physicians role in patient care, he recommends.

Example: In the above scenario, a good encounter note might read: I am providing management of the patients viral pneumonia. Heart failure as per management by the cardiologist.

Tip: If you are worried about submitting a claim with the same diagnosis as another physician, call to be sure each practice is reporting the diagnosis codes in the proper order.