The Coding Institute PULMONOLOGY CODING ALERT

1 PULMONOLOGYCODINGALERTPULMONOLOGYCODINGA LERT2009, Vol. 10, No. 12 (Pages 89-96)Your practical adviser for ethically optimizing CODING , payment, and efficiency in PULMONOLOGY practicesWhat s InsideAvoid Unnecessary Ire from CMS: Don t OveruseVAP Diagnosis ..91 XWhile not yet a non-event, CMS has its eye on Pulmonary DiagnosesCoding With These Proven Tips ..91 XFocusing on acuteconditions, exacerbations canwhip these claims into Be the Coder Rest Home Service Versus CPO ..92 Don t Overlook 3 KeyCoding Opportunities forPulmonology Claims ..93 XYou could be turning awayyour rightful reimbursement forscores of QuestionsLearn How to Code MultipleXolair t Get Stumped byObservation You Bill Incident ToUsing 1 NPI? ..95 Eliminate VAP Uncertainty With ClearDiagnosis Parameters and E/M OptionsXTip: Other conditions mimic ventilator-associatedpneumonia and can lead to pneumonia (VAP) is a difficult diagnosis to make, but oncethe pulmonologist diagnoses it in a patient, your E/M options may diagnostic accuracy and pinpoint E/M levels with these from-the-fieldVAP CODING Precise When Reporting VAPWhen you come across a case of suspected VAP ( ), consider how long thepatient has been on a ventilator before showing signs of pneumonia.

2 In general, VAPrefers to pneumonia that occurs more than 48 hours after endotracheal intubation,according to the Cleveland Clinic ( ).While diagnosis may seem straightforward, the diagnosis of VAP ischallenging, remarks Steven M. Gordon, MD,chairman of the department ofinfectious disease in the Medicine Institute at the Cleveland Clinic in Ohio. Often,pulmonologists do not perform bronchoscopies to obtain specimens or order chestcomputed tomographies (CTs) when making a diagnosis, Gordon says. In manycases, a physician treating pneumonia for a patient on a ventilator would simply codethe diagnosis as may want to consider alternate diagnoses before documenting VAP. Conditionssuch as heart failure ( ), hemorrhage ( ), acute respiratory distress syndrome(ARDS, ), and influenza ( ) can all look like VAP, Gordon points this:To rule out VAP, I would look at bronchoalveolar lavage (BAL), a chestCT, cultures of endotracheal secretions, or mini BAL for indicators, shares two:According to ICD-9 guidelines, you should also use an additional codeto identify the organism causing the infection.

3 Most of these infections are due to gramnegative organisms, such as Pseudomonas, or staph (methicillin-susceptible staphaureus [MSSA] or methicillin-resistant staph aureus [MRSA]), explains Alan , MD,professor of medicine in the division of pulmonary, allergy, and criticalcare at Emory University School of Medicine in CODING InstitutePage 90 Get CPC certified in 4 days , Vol. 10, No. 12/ PULMONOLOGY CODING AlertThe CODING Institutealso publishes the following newsletters. Call (800) 508-2582 for free samples: PULMONOLOGY CODING ALERT (ISSN 1529-6121 [print] ISSN 1947-7600 [online]) (USPS # 019-442) is published monthly by TheCoding Institute , a subsidiary of Eli Research, 2222 Sedwick Road, Durham, NC 27713. 2009 The CODING Institute . Allrights reserved. Subscription price is $347. Periodicals postage is paid at Durham, NC, 27705 and additional entry : Send address changes to PULMONOLOGY CODING AlertPO Box 413006, Naples, FL Customer Discussion : USA: 1 year.

4 $347; 2 yrs. $674 (save $20); 3 yrs $991 (save $50). Bulk prices available upon request. Credit cards accepted: Visa, MasterCard, American Express, codes, descriptions, and material only are copyright 2009 American Medical Association. All Rights Reserved. No feeschedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data containedherein. Applicable FARS/DFARS Restrictions Apply to Government CODING Alertis independent and not affiliated with any organization, HMO, vendor, or company. Reasonableattempts have been made to provide accuracy in the content. However, of necessity, examples cited and advice given in a nationalperiodical such as this must be general in nature and may not apply to any particular case. Further, medical CODING is part science,part art; even experts sometimes differ.

5 Also, clinical and other circumstances may differ between cases and thereby affect , neither the publisher, editors, board members, contributors, nor consultants warrant or guarantee the information containedherein on CODING or compliance will be applicable or appropriate in any particular situation. For information tailored to your specificcircumstances, consult a qualified information on copyright violations? Call us! We'll share with you 25% of the net proceeds of all awards related tocopyright infringement that you bring to our attention. Direct your confidential inquiry to Samantha Saldukas, (239) 280-2301, fax(239) 790-3803, or e-mail publication has the prior approval of the American Academy of Professional Coders for Education Units. Granting of this approval in no way constitutes endorsement by theAcademy of the content.

6 Call The CODING Institute at (800) 508-2582 for more information about how toreceive your INFORMATIONWe would love to hear from you. Please sendyour comments, questions, tips, cases andsuggestions for articles related to pulmonologycoding, reimbursement, or compliance to Liisa Sullivan at Box 413006, Naples, FL 34101-3006 Phone:(800) 508-2582 Fax:(800) 508-2592 Executive Editor:Liisa Editors:Alan Plummer, MDCarol Pohlig, BSN, RN, CPC, ACSE ditorial Director:Mary Compton, PhD, Publisher:Jeanne of Development:Bridgett Hurley, JD, Gardiner Saldukas of Sales:Bill Group Manager:Aleshia Elismond Conference Manager:Mariangela Marketing Manager:Margaret Monthlies:Anesthesia & Pain ManagementCardiologyEmergency MedicineFamily Practice GastroenterologyGeneral Surgery Thus, when reporting ventilator-associated pneumonia,you might code.

7 And (Pneumonia due to Pseudomonas) and (Methicillin susceptiblepneumonia due to Staphylococcus aureus), or and (Methicillin resistant pneumoniadue to Staphylococcus aureus).Make the Right Call on E/M LevelThe E/M service level for VAP would depend on thedocumentation the pulmonologist provides, observesBecky Zellmer, CPC, MBS, CBCS,medical billing andcoding supervisor for SVA Healthcare in 1:For instance, if the pulmonologist ismonitoring the ventilator and the patient does not requirecritical care, then using the ventilator management codes(94002-94004) may be an option, Zellmer says. Note: SeePulmonology CODING ALERT , Vol. 10, No. 10 for more onventilator management CODING and reimbursementcomparisons between these and other E/M 2:Alternatively, you may report one of thesubsequent hospital visit codes (99231-99233) accordingto the hospital note detailing the complexity of recentevents, the exam, and the medical decision making.

8 Option 3: If the VAP is severe or causes an acuteexacerbation of the underlying illness, then documentingand using one of the critical care codes (99291 [Criticalcare, evaluation and management of the critically ill orcritically injured patient, first 30-74 minutes] andpossibly +99292 [..each additional 30 minutes]) may bemost appropriate and would also result in the highestamount of reimbursement. VAP increases the complexityof the patient s illness(es) in the intensive care unit (ICU).. and usually leads to the necessity to code criticalcare, says that if you select a critical care code, thepatient s condition, the highly complex interventions, andthe time the physician spends with the patient must bedocumented correctly in the chart, says Zellmer. Representthe first 30-74 minutes of care with 99291 and subsequent30-minute episodes of care with + out:Don t confuse the need to manage aventilated patient with the need for critical care to CMS, Daily management of a patient onchronic ventilator therapy does not meet the criteria forcritical care unless the critical care is separately identi-fiable from the chronic long term management of theventilator dependence.

9 Note: For more on meetingcritical care criteria, reference CMS Transmittal 1530 andMedLearn Matters article : Most patients with suspected VAP willreceive broad spectrum antibiotics (extended spectrumpenicillins, cephalosporins, or quinilones), says a ventilator-assisted patient would be a hospitalinpatient or long-term care resident, the facility, ratherInternal MedicineNeurology Neurosurgery Ob-GynOncology & Hematology OphthalmologyOptometryOrthopedics OtolaryngologyPathology/Lab PediatricsPhysical Medicine & RehabRadiology UrologyOther Newsletters:Medical Office Billing & Collections AlertMedical Office Front Desk ProPart B InsiderPulmonology CODING ALERT /2009, Vol. 10, No. 12To subscribe, call (800) 508-2582 Page 91than the pulmonologist, would report the antibioticadministration. The course of treatment would not bereported per se, but would be incorporated into thephysician work used to document a 99291 (critical care)or 99233 (subsequent hospital care) visit, says :Find Guidelines for the Management ofAdults with Hospital-acquired, Ventilator-associated, andHealthcare-associated Pneumoniaon the AmericanThoracic Society Web site at Master Pulmonary DiagnosesCoding With These Proven Tips XFocusing on acute conditions, exacerbations can whip these claims into reporting asthma, acute bronchitis, chronicobstructive pulmonary disease (COPD), obstructivebronchitis, and emphysema depends on thepulmonologist s documentation in the patient s medicalrecord.

10 Making sure the documentation supports thepatient s diagnosis and that you code for any associatedacute conditions will ensure that you re correctly reportingpulmonary for Manifestations When Choosing Asthma CodeYou can find all the asthma codes in the 493 categoryof the ICD-9 codes. Look to for asthma withairflow limitation. Airflow limitation may occur inasthmatic patients with persistent disease or those patientswith asthma of long three asthma codes with airflow limitationdemonstrated by pulmonary function testing you ll choosefrom are: Chronic obstructive asthma; unspecified .. with status asthmaticus .. with (acute) can be associated with asthma. When yourphysician diagnoses both COPD and asthma together,you ll refer to his documentation in the medical record to(Continued on next page)Avoid Unnecessary Ire fromCMS: Don t Overuse VAPD iagnosisXWhile not yet a non-event, CMS hasits eye on pneumonia (VAP) is in theundesirable category of hospital-acquired conditions but if CMS has its way, the need for making thediagnosis would occur much less has tried to place VAP ( ) into the non-reimbursable event category of hospital-acquireddiseases and conditions that carriers will not pay category includes events such as operating on thewrong limb, leaving equipment in the patient, etc.