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E/M + Bronchoscopy + PFT: Unlock the Secrets to Signs and Symptoms Coding

Keep your CCI edits in mind for PFT bundles.

When a patient presents with common respiratory conditions, your pulmonologist should perform an extensive history and examination, and may order several diagnostic tests before he can settle with a definite diagnosis to report in the claim. Along with the primary diagnosis (if achieved), you should report the patient’s signs and symptoms or else risk an audit.

Consider this scenario: The pulmonologist sees a patient for fever, shortness of breath, chest pain, weight loss, and fatigue. After undergoing a detailed history and examination, the patient becomes suspect for hypersensitivity pneumonitis, otherwise known as extrinsic allergic alveolitis (495.x). The physician orders a diagnostic bronchoscopy with fluoroscopic guidance, as well as a spirometry to verify the patient’s condition. To justify each service performed by the same provider or group, you might be accumulating payer inquiries or denials. This 2-step technique should carry you through potentially puzzling spirometry-E/M coding situations.

1. Don’t Leave Out Signs and Symptoms On Your Claim

 First on your to-do list is to report the patient’s signs and symptoms. In this case, you would code 780.6 (Fever and other physiologic disturbances of temperature regulation), 786.05 (Shortness of breath), 786.50 (Unspecified chest pain), 783.21 (Loss of weight), and 780.79 (Other malaise and fatigue). Because these signs and symptoms resemble other respiratory problems, the physician performs a level four E/M and orders some diagnostic tests. Report the procedures with: 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) for the bronchoscopy with fluoroscopic guidance. Your physician is likely to perform this on a separate date. 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for the pulmonary function test (PFT); and 99214 (Office...

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June 24, 2011
Hot Coding Topics

Therapy Progression Is Your Key to Correct Whiplash Coding

Be on a look out for Scans, TPIs, and more

Though coding for whiplash diagnosis and treatment is pretty straightforward, you should still watch out situations when the patient’s symptoms persist despite conservative therapy and warrant more extensive treatment. You will miss your pay if you miss these diagnoses.

When a patient presents with whiplash symptoms, your pain management specialist will conduct a thorough exam and will often order neck x-rays to rule out fractures. On diagnoses of whiplash (847.0, Sprains and strains of other and unspecified parts of back; neck sprain), he typically will prescribe conservative treatment. Common options include physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants. Some patients may also benefit from wearing a soft cervical collar or by using a portable traction device.

If conservative treatment fails, the physician might order additional diagnostic imaging tests. These could include:

  • CT scans – 70490 (Computed tomography, soft tissue neck; without contrast material), 70491 (… with contrast material[s]) and 70492 (… without contrast material followed by contrast material[s] and further sections)
  • MRIs – 70540 (Magnetic resonance [e.g., proton] imaging, orbit, face and/or neck; without contrast material[s]), 70542 (… with contrast material[s]) and 70543 (… without contrast material[s], followed by contrast material[s] and further sequences)
  • Bone scans – CT, MRI, and x-ray tests include basic bone scans. If your physician orders more extensive bone scans for the patient, you might to get authorization for 78300 (Bone and/or joint imaging; limited area) or 78305 (… multiple areas) instead.

Correctly Count Trigger Point Injections

Your physician might also administer trigger point injections to relieve the patient’s pain and muscle tenderness. Code these procedures with 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) or 20553 (…three or more muscles).

Because of the “one or two muscles” and “three or...

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February 5, 2011
Coding Challenge / E/M / modifier 25 / modifier 26 / radiology

Use 3 CPT, Modifier, and ICD-9 Code Pairs to Ace This X-Ray Claim

Decipher why you should include a seconding diagnosis.

Question: A 38-year-old patient presents to the emergency room with complaints of wheezing, coughing, and trouble catching her breath. After the nonphysician practitioner (NPP) performs a problem-focused history, the physician performs a detailed history and exam and discovers focal ronchi. The physician orders a two-view chest x-ray to check for upper respiratory infection (URI) The chest x-ray results reveal acute URI, and the ronchi clears up upon reevaluation. The patient is treated with antibiotics. How should I code this scenario?

Answer:You’ll submit two of each for this claim: CPT codes, modifiers,and ICD-9 codes. On the claim, report the following:

  • 71020 (Radiologic examination, chest, 2 views, frontal and lateral) for the x-ray
  • Modifier 26 (Professional component) appended 71020 to show that you are coding for the physician’s services only
  • 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination;and Medical decision making of moderate complexity….) for the E/M
  • Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 show that the E/M and the x-rays were separate services
  • 465.9 (Acute upper respiratory infections of multiple or unspecified sites; unspecified site) appended to 71020 and 99284 to represent the patient’s URI
  • 786.7 (Symptoms involving respiratory system and other chest symptoms; abnormal chest sounds) appended to 71020 and 99284 to represent the patient’s focal ronchi.

Secondary Dx decoded: Even though the focal ronchi cleared up on reexamination, you should still include 786.7 on the claim. It will help paint a more lucid portrait of the patient’s condition, and can only strengthen your medical necessity case for the chest-x-ray.

@ Part B Insider. Editor:...

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May 24, 2010
Coding Challenge / E/M / modifier 25 / modifier 50

How Do I Code a 2-Sided Nosebleed?

Heads up: 2 nosebleed codes are not the answer. Question: A patient reports to the ED after sustaining injuries during a soccer match; she was hit in the face with a ball, her nose is bleeding, and her right eye is blackened. The physician is not able to stop the bleeding with ice or pressure, so [...] Related articles:

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January 19, 2010
Coding Challenge / ICD-9

What’s the Correct Diagnosis Code for a Urine Drug Test?

Question: What is the proper ICD-9 code when the lab performs a urine drug test? Answer: ICD-9 does not provide one specific code for a urine drug test. The correct diagnosis code to report when billing for the lab test depends on the signs, symptoms, patient condition, or other reason for the test, such as screening. [...] Related articles:

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October 19, 2009