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Pulmonary Billing: Shortness of Breath in Unspecified Codes

March 25, 2013

Pulmonology Medical BillingIt’s been the usual whirl of reviewing CMS manuals, commercial coverage determinations, the Federal Record, and still coding and submitting clean claims without missing a beat. It’s a tough job, but we enjoy serving our clients’ needs. For example, we had an interesting Pulmonary situation that resulted in a long and thought-provoking discussion about (what else?) ICD-10 and how it will affect outpatient pulmonary billing.

It takes a special kind of medical biller to specialize in pulmonary . While outpatient consultations and follow-up appointments make up the bulk of a Pulmonary practice’s A/R, there are also inpatient visits, and a variety of tests and procedures. Coding and billing these variations takes experienced attention to detail. In addition, many respiratory diagnoses are pretty specific in ICD-9-CM. A solid background of anatomy and physiology, as well as respiratory pathology, is essential for effective pulmonary billing. That, and the proper use of modifiers, bundling and un-bundling concepts, and CLIA exemptions.

The original question had to do with what place of service to use when a physician’s assistant sees an established COPD patient in the ICU. For those readers wondering if this is a question about outpatient billing, the answer is technically yes and no. These services get billed on a CMS-1500 the same as any other physician services, so in that sense, yes. There are some different codes used to show that the claim is for inpatient services rather than the physician office setting, so in that case, no. It’s a situation we encounter every day, not just in pulmonary but in other medical specialties, as well.

After the issue was settled, our coder asked the PA what the patient’s diagnosis code would be. He said he was going to assign 496.

There probably isn’t a coder alive, except those that deal with neonates or pediatrics, that doesn’t know that 496 is the default code for chronic obstructive pulmonary disease. It is a non-specific code that is frequently used to describe COPD without being able to differentiate between variations and severity of the condition. This is under the current coding system, ICD-9-CM. Under ICD-10-CM, that is going to change.

Here at M-Scribe, we are getting ready for the changes that are going to take place with pulmonology ICD-10 billing. Medical practices that are preparing now are predicted to suffer no ill effects from the ICD-10 transition. Practices that aren’t prepared will probably see a drop in immediate cash flow, delayed payments, increased denials, and an increased exposure to pre- and post-payment audits. The change to ICD-10 is serious business, and serious business people are taking the appropriate steps to ensure their transition is seamless.  

ICD-10-CM offers a much wider scope of possible codes to describe pulmonary diagnoses. The increased specificity of the new coding methodology will more accurately reflect the contents of the medical record, and it will more accurately describe the medical necessity for procedures. This is already critical for billing compliance, but the need will be even greater, by design, under ICD-10. 

We are working with all our clients to ensure a seamless transition. We don’t expect any problems. When we partner with physician practices, we work hard, and it’s what we enjoy: making practices perfect®.


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