Pulmonology Coding Alert

Signs and symptoms may sometimes be your best choice

Choosing the right CPT procedure code is the first step to ensure your pulmonologists get paid for the work they do, but if you fail to attach the correct ICD-9 code, you may be in jeopardy of receiving denials.

Follow these expert recommendations to ensure you're properly coding patients' signs, symptoms and diagnoses.

Watch for Final-Digit Requirements

Correct coding requires that you code as specifically as possible. That means your pulmonologist should assign the most precise ICD-9 code to a service. You cannot justify a service with a three- or four-digit diagnosis code when carriers or ICD-9 requires a more specific four- or five-digit code to describe the patient's condition.

"Using the fourth or fifth digit when it is required is an important concept to follow," says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, Fla. Make sure you review the entire record when determining the specific reasons for the encounter and the conditions the physician treated, she says. You should not arbitrarily assign an additional digit without referring to the information present in the medical record.

Example: If you are coding for pneumonitis (507), you cannot simply report 507. Three digits alone don't make for a complete diagnosis. Instead, you must specify a fourth digit to indicate what the pneumonitis is due to. Use a fourth digit of:

• 0--pneumonitis due to inhalation of food or vomitus

• 1--pneumonitis due to inhalation of oils and essences

• 8--pneumonitis due to other solids and liquids.

Tip: If the medical record does not allow you to code to the required specificity level, check with the reporting pulmonologist for guidance. Don't assume what's not in the medical record. The pulmonologist, not the coder, is responsible for assigning the diagnosis.

Search for Definitive, Not Rule-Out, Dx
 
ICD-9 coding guidelines state that you should not report "rule-out" diagnoses in the outpatient setting. You'll avoid labeling the patient with an unconfirmed diagnosis.
Do this: "Look to see if the physician has given the patient a definitive diagnosis," says Denae M. Merrill, CPC, coder for Covenant MSO in Saginaw, Mich.        " 'Rule out,' 'suspected,' 'probable' or 'questionable' are not codable."

Example: A patient presents with a chronic cough that she's had for more than three weeks. The patient shows no other asthmatic symptoms, such as shortness of breath (786.05) or wheezing (786.07). To test the patient for cough variant asthma (CVA), the pulmonologist orders spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximum voluntary ventilation) for the patient, which returns with normal results.
 
A methacholine bronchial challenge (95070, Inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds; 94070, Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents [e.g., antigen(s), cold air, methacholine]; J7674, Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg) follows, which also shows normal results. The pulmonologist orders an upper gastrointestinal series, which demonstrates moderate esophageal reflux (530.81), ruling out CVA.

The pulmonologist should report the diagnostic tests and the definitive diagnosis of esophageal reflux (530.81), not the rule-out diagnosis of CVA (493.82). Because a level-1 Correct Coding Initiative (CCI) edit exists on 94010 and 94070, the coder should append modifier 59 (Distinct procedural service) to 94010 to indicate that the spirometry was a separate test from the bronchospasm provocation evaluation, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

Find Out When to Use Signs and Symptoms

When the pulmonologist cannot assign a definitive diagnosis, look for any signs or symptoms that the patient has been having. By coding the presenting signs and symptoms, your physician will still get paid for the services, even if he cannot establish a definitive diagnosis.

CMS outpatient services guidelines explicitly state that practices should not use the condition being ruled out as the diagnoses. Instead, "code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results ..."

Example: An established patient with severe coughing and chest pain presents to your practice. Your pulmonologist performs an evaluation and, suspecting pleural effusion, orders a chest x-ray, which comes back negative. Because no definitive diagnosis is available and ICD-9 disallows reporting suspected diagnoses, you should report the signs and symptoms--chest pain (786.50) and cough (786.2)--linked to the E/M service (such as 99201-99215, Office or other outpatient visit ...).