Coding Consult

Documenting consults

Q. My partner thinks that when we want a consult, we must include a written request in the patient's records. Is he right?

Experts recommend that the requesting physician's office fax the request for consult on the doctor's letterhead or prescription form. This removes any perception that the consulting physician created the need for the consult when in fact the visit was a referral.

Pulmonary function tests

Q. How do I report pre- and post-treatment pulmonary function tests?

A. If you perform a bronchospasm evaluation to determine the patient's responsiveness to treatment, report 94060 (bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration).

Carriers don't consider the bronchodilator cost as part of the payment for 94060. CPT suggests reporting 99070 (supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies or materials provided]) or the appropriate drug code.

If you report a drug code, choose a HCPCS code that identifies the specific drug and the amount you administered. If you use Albuterol, you might select J7613 (Albuterol, inhalation solution, administered through DME, unit dose, 1 mg).

But if the patient has an acute exacerbation of asthma, and you administer an inhaled bronchodilator, report 94640 (pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) in addition to the appropriate J code.

Asthma codes

Q. A patient with a history of asthma developed bronchitis. How should I code the bronchitis? Should I report an asthma code?

A. That depends. Use 466.0 (acute bronchitis) as the primary-and possibly only-diagnosis.

If the patient's asthma is under control and isn't causing any problems, the condition may not warrant using an additional ICD-9 code to report the asthma. But if his asthma affects the encounter-for instance, his asthma medication impacts the bronchitis's treatment-report the asthma in addition to bronchitis.

Avoid using an unspecified asthma code. Some insurers will deny the claim, or you may have to submit additional notes. Assign the appropriate five-digit asthma code when you first submit the claim.

This information is adapted from material provided by the Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact the Coding Institute, 2272 Airport Road South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592 or visit http://www.codinginstitute.com.