Pulmonology Coding Alert

When you are coding post-lung transplant care, be sure you report the correct diagnosis codes as well as the appropriate tests performed to ensure you receive full reimbursement for your services. Frequent patient follow-up visits by the lung transplant team, including the pulmonologist and transplant surgeon, are crucial during the first few months following a lung transplant. In addition to monitoring the functions of the new graft and immuno-suppressant drug levels, the pulmonologist may also prescribe and review tests and administer medication if the patient develops an infection or is at risk for rejection. Signs and Symptoms Show Medical Necessity When problems are caused by medication, infection or the threat of rejection, properly coding the signs and symptoms is important until a definitive diagnosis is made. Those signs and symptoms can vary. Typical reactions include high fever (780.6) and high blood pressure (401.9), intense chest pain (786.5x), and a marked drop in urine output (788.5). More often, however, the symptoms are less dramatic, such as low-grade fever, decrease in urine output, pain and tenderness, and slight increase in blood urea nitrogen and creatinine levels (790.6, Other abnormal blood chemistry). You must also use the correct primary code to indicate rejection of a transplanted lung (996.84), and secondary diagnoses for the complications that can result in rejection, such as cytomegalovirus infection (078.5), are necessary for appropriate reimbursement. Remember to include V42.6 (Lung replaced by transplant) among the diagnoses when reporting post-transplant care. Code 99233 Requires Special Care Pulmonologists may prescribe high doses of steroids initially to treat suspected rejection symptoms. If a diagnosis is in doubt, a physician may investigate, using an ultrasound examination (76604, Ultrasound, chest, B-scan [includes mediastinum] and/or real time with image documentation) to detect pleural fluid collections, says Charlie Strange, MD, FCCP, director of the medical intensive care unit at the Medical University of South Carolina in Charleston. Consider this scenario: Two weeks after undergoing a lung transplant, the patient, still in the hospital, exhibits a high fever and elevated blood pressure, slightly reduced urine output, and moderate chest pain when he breathes. The pulmonologist examines the patient and orders and reviews the results of a chest radiography and multiple blood tests. Because the chest radiograph shows pleural effusion, the physician performs a thoracentesis after ultrasound evaluation of the pleural space.

Based on this information, says Nancy DeMarco Lamare, CPC, CCS-P, a multispecialty coder for Central Maine Clinical Associates in Lewiston, in Monmouth, Maine, you should report 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ) because two of the three components a detailed history and high-complexity decision-making necessary for choosing that E/M level are present: The E/M code should be appended [...]