Pulmonology Coding Alert

Look for documentation details when choosing between 78579, 78580 and 78582.

How confident are you when it comes to reporting a ventilation/perfusion scan (or V/Q study)? These tests are vital to confirm a life threatening diagnosis of pulmonary embolism. Any delays or miscommunication about codes or coverage could result in service not being covered.

Brush up on the Basics: A pair of nuclear scan tests — pulmonary ventilation/perfusion scan — measure two things: the distribution of blood within the capillaries surrounding the alveoli in the lungs (perfusion), and the distribution of oxygen within the same alveoli (ventilation). The provider administers a small amount of low—risk radioactive substance through inhalation in the ventilation scan, or injection in the patient’s arm in the perfusion scan. The provider may perform these tests separately or together.

Know the indications: Typically, your provider may order a V/Q scan to:

• Diagnose a pulmonary embolism (PE), a sudden blood clot blocking a blood vessel in the lung.
• Detect the quality of blood flow in the lungs
• Prep for lung surgery.

“Knowing which test is being ordered will ensure that the correct study is chosen and pre-certified for your patients.” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. To arrive at an accurate code for the encounter, and clear coding blind spots, follow these handy pointers on lung scanning.

1. Zero In on a Ventilation Scan

How do you go about identifying which scan the provider ordered? Begin with a review of the intent of the scan.

Look for details on inhalation first: To confirm whether the physician selected a ventilation study, search through the records for terms such as “gases” or “inhalation.” The patient inhales oxygen aerosol with particles of a radioactive gas (generally xenon), and images are taken in multiple positions. You may also comb through the notes for other terms such as “DTPA,” “Technetium DTPA,” “particulate,” and “mist.”

Here, you would choose code 78579 (Pulmonary ventilation imaging [e.g., aerosol or gas]) for a diagnostic imaging study of lung ventilation using a radiopharmaceutical aerosol to record its distribution within the lungs.

2. Pinpoint a Perfusion Study with Injections

Documentation clues to a perfusion study: The injection of the radioisotope is unique to a perfusion study. In the notes, you may find references to injections of “TC—99m MAA,” or “Technetium MAA,” macroaggregated albumin or “macrospheres.” These terms will confirm that you are about to report a perfusion study.

You may select code 78580 (Pulmonary perfusion imaging [e.g., particulate]) for a diagnostic imaging study of lung perfusion using injection of a radioisotope to record its distribution within the pulmonary arterial blood flow.

3. Crack Coding For Combined Procedures

In another scenario, suppose your provider chooses a combined procedure to determine both pulmonary perfusion and ventilation.

Typically, perfusion and lung ventilation scans almost always go together, to detect

• Characteristic patterns of perfusion deficits.
• Emboli and for documentation of resolution during and after therapy.

The procedure: The provider obtains images after the patient inhales an aerosol with a readiopharmaceutical to evaluate pulmonary ventilation and takes images again after injection of a radioactive particulate to determine lung perfusion.

In this scenario, you may report the combination code 78582 (Pulmonary ventilation [e.g., aerosol or gas] and perfusion imaging).

Note:  Do not make the mistake of using modifier 52 (Reduced services) along with the combination code 78582 if the provider performs only one component of the study. Just report the perfusion code 78580 or the ventilation code (78579) there is no need to append modifier 52.

4. Get a Step Ahead With Coding Differential Scans

Differential scans help the provider quantitatively measure and compare the perfusion and ventilation of the two lungs in patients with lung pathology resulting in unequal distribution of blood flow or air flow in the two lungs.

Differential perfusion scan: If the physician ordered differential scans, you may report code 78597 (Quantitative differential pulmonary perfusion, including imaging when performed) for a comparative lung perfusion study using a radiopharmaceutical to measures relative distribution of pulmonary arterial blood flow in each lung.

Differential V/Q scan: If the provider opts for both differential pulmonary perfusion and ventilation study, you may report code 78598 (Quantitative differential pulmonary perfusion and ventilation [e.g., aerosol or gas], including imaging when performed).

Code 78598 represents the same work as 78597, along with addition of a differential ventilation study.

Important: Both these codes include imaging when performed and you cannot report any additional codes for the imaging. The imaging can be a magnetic resonance imaging (MRI) or other radiological imaging that your radiologist obtains during the scan.

The road ahead: Have a check list that you can go through on each patient when the provider schedules this test, says Lisa Center, CPC, Physician Practice Manager at Via Christi Hospital Pittsburg, Inc., in Pittsburg, Ks.

While “knowing which test is best for the patient will be the physician’s task …communicating this information effectively to the patient will also be delegated to the clinical staff,” Pohlig says.

An accurate knowledge of these codes and picking up the right keywords from notes is essential for successful claims. “Billers and coders will need to understand the difference between these studies to ensure that he patient’s insurance covers the test ordered by the physician, and the pre-certification process goes smoothly (if required),” Pohlig says.