General / Hot Coding Topics / Provider News

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...

Comments Off on E/M + Bronchoscopy + PFT: Unlock the Secrets to Signs and Symptoms Coding
June 24, 2011
Coder's Cranium / General / Hot Coding Topics / Provider News

Modifier 57 Remains Handy Post Removal of Consult Codes

Take a hint from a CPT®’s global period when choosing between modifiers 25 or 57

Contrary to popular thinking, modifier 57 does not apply exclusively for consultation codes only. Medicare may have stopped paying for consult codes, but this doesn’t mean you have to stop using modifier 57. Here are two tips on how you can use this modifier to suit your practice’s needs.

Background: Starting January 1, 2010, the Centers for Medicare and Medicaid Services (CMS) eliminated consult codes from the Medicare fee schedule.

Non-Consult Inpatient Codes Keep Modifier 57 Alive

With CMS eliminated consult codes (99241-99245, 99251- 99255) for Medicare patients, you might have wondered if modifier 57 (Decision for surgery) would remain useful. The answer? You can still use this modifier for a non-consult inpatient E/M code, so long as your documentation supports it. This is because any major procedure includes E/M services the day before and the day of the procedure in the global period, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “The only way you can be paid properly for an E/M performed the day before the major surgery or the day of the surgery is to indicate that it was a decision for surgery (modifier 57), which also indicates to the payer that the major procedure was not a pre-scheduled service,” she explains.

Past: Say the pulmonologist carries out a level four inpatient consult in which she figures out the patient requires thoracoscopy with pleurodesis for his recurring, persistent pleural effusion (511.9). The physician decides to perform thoracoscopy with pleurodesis the day after the consult. In this case, appending modifier 57 to the E/M code (99254, Inpatient consultation for a new or established patient, which requires these 3...

Comments Off on Modifier 57 Remains Handy Post Removal of Consult Codes
June 24, 2011
Hot Coding Topics

Inhaler Education Claims: 4 Quick Guidelines to Help You Report Correct Claims

When reporting inhaler service, you should remember the type of device the provider is using, but shouldn’t stop with just that. Documentation requirements and qualifying modifiers are just as important when coding for inhaler services.

When you’re confused why some payers would deny reimbursement for certain inhaler claims, the following ideas could guide you to a better understanding of how inhaler service codes work out.

94664 Is Your Ticket to Diskus Demo Pay

The Advair Diskus is an “aerosol generator.” If the nurse/medical assistant taught someone to use an Advair Diskus — or any other diskus — you should report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

For example, a pulmonologist starts a patient with asthma (493.00, Extrinsic asthma; unspecified or 493.20, Chronic obstructive asthma; unspecified) on Advair. A nurse then teaches the patient how to use the Diskus. As per CPT guidelines, you should report 99201-99215 for the office visit and 94664 without a modifier, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

In addition, CMS transmittal R954CP also indicates that modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) applies only to E/M services performed with procedures that carry a global fee, which 94664 does not have.

Nonetheless, many payers will only pay for the service if you append modifier 25 to the visit code. It’s always best to check with your major insurers’ policy first.

Bundle Dose in Teaching Session

The patient may administer medication dose during the teaching session. Both services (treatment + teaching) are bundled into one CPT: 94640 (Pressurized or nonpressurized inhalation treatment for acute...

Comments Off on Inhaler Education Claims: 4 Quick Guidelines to Help You Report Correct Claims
March 16, 2011
Coding Challenge / ICD-10 / ICD-9

Coding Generalized Bronchitis? Prepare for Denials

Relying on the physician’s encounter form could be a big mistake.

Question: I used 491.9 to report a patient’s bronchitis, but the payer denied my claim and requested additional information. What was wrong?

Vermont Subscriber

Answer: Your claim may have...

Comments Off on Coding Generalized Bronchitis? Prepare for Denials
March 23, 2010
Coding Challenge

Separate Sleep Study Coding from Your H&P Coding

Don’t separately report a cursory H&P from the sleep code.

Question: If a nurse practitioner (NP) performed an H&P (history and physical exam) or a subsequent visit with a patient prior to a sleep study, can you bill the H&P...

Comments Off on Separate Sleep Study Coding from Your H&P Coding
March 21, 2010
Coder's Cranium

Set the Record Straight: ICD Code Options for COPD

What your pulmonologist writes in the documentation matters. The pulmonologist’s documentation, along with the patient’s medical record can make or break your chronic obstructive pulmonary disease (COPD) reporting. One key is making sure that your coding accurately identifies the patient’s specific pulmonary condition and any other associated acute condition (if necessary). Background: According to the National Heart [...] Related articles:

  1. 3 Pulmonary Diagnosis Coding TipsRemember to focus on acute conditions & exacerbations. Correctly reporting...
  2. How Do You Code COPD With Acute Bronchitis?  Question: An established patient with chronic obstructive pulmonary disorder (COPD)...
  3. Should You Code Presenting Symptoms Along With Dx? Question: An established patient complains of trouble breathing and...

Comments Off on Set the Record Straight: ICD Code Options for COPD
February 25, 2010
Coding Challenge

How Should I Code a Fibrinolytic Agent Instillation Via Chest Tube?

Different calendar dates matter, but multiple instillations the same day do not. Question: My pulmonologist inserted a chest tube and then instilled a fibrinolytic agent to break up multiloculations to free up an entrapped lung. Usually, I use 32560 for this procedure, which is for pleurodesis, not fibrinolysis. What code should I use for fibrinolytic agent [...] Related articles:

  1. Radiology Coding: CPT 2010 Breathes New Life Into Your Respiratory CodingMaster 32561’s guidelines to prevent a major units gaffe. Flip...
  2. Signs & Symptoms Coding Coach: Chest Pain 786.50-786.59: One of the most common symptoms that cardiovascular...
  3. PFS Treasure Chest: Read Medicare’s MindIt seems like dry reading, but the physician fee schedule...

Comments Off on How Should I Code a Fibrinolytic Agent Instillation Via Chest Tube?
January 27, 2010
Coding Challenge

Pulmonology Coding Challenge: Why Are My 94664 Claims Getting Denied?

Before coding 94664, check off these items. Question: Under the direction of my pulmonologist I recently submitted 94664 for reimbursement for training time, but the bill was rejected? Can I challenge this? Answer: You can challenge training denials, provided your documentation supports the education’s reason. However, “not all payers will pay for 94664,” notes Gary N. Gross, [...] Related articles:

  1. Surgery Coding Challenge: Master Microsurgery Units With This AdviceCheck your EOB to make sure payers don’t apply a...
  2. 52214 Coding Challenge: Fulguration, Then TUIBNCQuestion: If my physician went to do a TUIBNC and...
  3. Radiology Coding Challenge: Why is Medicare Denying a 38792, 78195 ClaimTip: Discover true meaning of 38792 note Question: The physician...

Comments Off on Pulmonology Coding Challenge: Why Are My 94664 Claims Getting Denied?
January 21, 2010