Frequently Asked Questions about Pharmacy Prior Authorization

Frequently Asked Questions about Pharmacy Prior Authorization

A December 2017 study from the American Medical Association reported that 86 percent of physicians said that prior authorizations have increased during the prior five years, with 51 percent saying that they have increased significantly. The PA process for approval of high-cost specialty medications is burdensome, and costs pharmacies and physicians’ practices a lot in terms of time and money. Pharmacy prior authorization distracts from patient care, can delay care and even cause patients to abandon treatment. Outsourced insurance authorization services are a practical option for physicians to standardize in-office processes for handling prior authorizations, obtain prior approval quickly, and get paid for services provided.

Here are answers to frequently asked questions about pharmacy prior authorizations:

  • What is pharmacy prior authorization?
    Prior authorization (PA) is a requirement that healthcare providers obtain advance approval from a health plan before a specific procedure, service, device, supply or medication is delivered to the patient to qualify for payment coverage. Pharmacy prior authorization is the requirement for approval from the patient’s health plan for a prescription drug.
  • Why do health insurance companies require pharmacy prior authorization?
    Health insurance companies use a PA as a means to ensure that a drug prescribed is truly medically necessary and appropriate for the patient’s situation. PA is a method for minimizing costs by ensuring that the prescribed drug is the most economical treatment option available to treat the condition. For example, if the physician prescribes an expensive drug, the insurance company may authorize it only if the physician can show that it is a better option than a less expensive medication for the condition.
  • What types of drugs require PA?
    According to Consumer Affairs, the following kinds of drugs are subject to PA:

    • Brand name medicines that are available in a generic form
    • Expensive medicines, such as those needed for psoriasis or rheumatoid arthritis
    • Drugs used for cosmetic reasons such as medications used to treat facial wrinkling
    • Drugs prescribed to treat a non-life threatening medical condition
    • Drugs not usually covered by the insurance company, but said to be medically necessary by the prescriber
    • Drugs usually covered by the insurance company but are being used at doses higher than normal
  • Blue Cross Blue Shield requires prior authorization for those drugs:
    • that have dangerous side effects
    • are harmful when combined with other drugs
    • should be used only for certain health conditions
    • are often misused or abused
    • are prescribed when less expensive drugs might work better
  • What are the steps involved in the pharmacy prior authorization process?
    The physician prescribes a specific drug. If the prescription requires PA, the pharmacy will contact the physician who prescribed the medication and inform the provider that the insurance company requires a PA. At this stage, the patient can either opt to wait for coverage approval from the insurance company or pay for full cost of the prescription themselves. The physician will contact the insurance company and submit a formal authorization request according to the plan’s guidelines,along with the necessary forms. The insurance company may also require the patient to complete some paperwork or sign some forms. The insurance company will review the request and may either authorize the drug or refuse to cover it.
  • What are the common reasons why a patient’s prior auth request may not be approved?
    • The patient did not give the insurance company, physician, and pharmacy enough time to complete the needed steps, which can take several business days.
    • The insurance company denied the claim
    • The insurance information was outdated or the claim was sent to the wrong insurance company
    • The medication was not medically necessary
    • Supporting evidence was inadequate
    • The physician’s practice did not contact the insurance company
    • The wrong PA code was used to bill the medication
    • Payer rules changed
    • The practice does not have the capability to manage PAs
    • The physician did not meet payer guidelines

In some cases, the approval of the drug may be valid for a limited time such as one year or one month. In such cases, the authorization process must be restarted.

  • How long does prior authorization take?
    Obtaining a prior authorization is a time-consuming process for physicians and their staff. A 2010 American Medical Association (AMA) survey, found that physicians spend about 20 hours of a traditional work week on PA activities. The AMA also reported that more than 60% of physicians said they needed to wait at least one business day to complete prior authorizations, while 30% said they have had to wait three business days or longer to get a response on a prior authorization request. Further delays occur if coverage is denied and must be appealed. An appeal can take several days to process.
  • What can be done if a prior authorization is denied?
    If patients believe that their pharmacy PA was incorrectly denied, they can appeal the rejected claim. They would need to first contact the insurance company and ask why the claim was denied. If the insurance company indicates a billing error or missing information, patients can work with their physician to review the paperwork and fix any errors that caused the denial. They can also ask the physician to provide backup evidence or notes that could help prove that the prescription is medically necessary. The chances of success in resolving a prior authorization denial are higher when the physician ensures that all clinical information is included with the appeal, including any data that may have been missing from the initial request.

Prior authorization stands in the way of proper and timely patient care. In an AMA survey of 1,000 practicing physicians, nearly 90 percent of the physicians reported that the administrative burden related to PA requests has risen in the last five years, with most saying it has “increased significantly”. Led by the AMA, physicians, payers and other stakeholders are working to improve the prior authorization process.

Outsourcing the insurance authorization task is a reliable option to ease this burden. This brings us to the question – how do insurance authorization services work?

Insurance authorization companies have experienced personnel who act as an enabler between the physician’s practice and the payer. These experts have extensive experience in working with all government and private insurances. They will collect the patient information from the practice to obtain prior authorization for medications and services. Insurance authorization services cover the following:

  • Verifying patients’ benefit information before the office visit, which will ensure clean claim submission.
  • Contacting payers to obtain pre-authorization quickly
  • Ensuring that payer criteria are met before submitting the request
  • Submitting all necessary documentation with PA requests
  • Managing any follow-up, such as getting more information from the physician for the pre-authorization
  • Support for appealing denials

Insurance verification and authorization support is often a part of outsourced medical billing services.

ICD-10-CM Coding For Certain Warm Weather Diseases

ICD-10-CM Coding For Certain Warm Weather Diseases

Warm weather diseases are caused mainly due to prolonged or intense exposure to hot temperatures. Exposure to such extreme heat can make a person seriously ill. The likelihood of illness also depends on factors such as physical activity, clothing, wind, humidity, working and living conditions, and a person’s age and state of mind. Some common warm weather diseases are insect bites, poison ivy, swimmer’s ear and heatstroke. Physicians treating such diseases need to use the correct ICD-10 codes to report the correct diagnoses. Relying on the services of an established medical billing and coding company can help in accurate and timely claim submission for appropriate reimbursement.

ICD-10-CM codes for Insect Bites

It’s common during summer to see and experience various bites and stings by insects, spiders, snakes, animals and marine life. Most of the time, these bites and stings do not cause serious problems. However, in rare circumstances, certain bites and stings can cause severe illness or even death in people who are sensitive to the venom.

When you are approached by a patient who has been bitten by an insect, first you have to verify venom before you report that bug encounter and finalize your code.

After the verifying check,start your search for codes in the ICD-10-CM Index to Diseases and Injuries, where the index entry for “Bite(s) (animal) (human)” has many subentries based on site, such as ankle, arm (upper), chin and so on. There is a separate subentry for “insect,” but it confirms that site is your best bet by instructing you to “See Bite, by site, superficial, insect.”

If your area is arm in the subentry example, then the ICD 10 codes are:

S40-S49: Injuries to the shoulder and upper arm

  • S41.15 Open bite of upper arm
    • S41.151: Open bite of right upper arm
    • S41.151A: …… initial encounter
    • S41.151D: …… subsequent encounter
    • S41.151S: …… sequel

Coding for a non-venomous insect bite is not the same as coding for a venomous spider bite, which you’ll report using the code

  • T63.3– Toxic effect of venom of spider

ICD 10 coding for a non-venomous insect bite is

  • W57– Bitten or stung by non-venomous insect and other non-venomous arthropods

ICD-10-CM codes for Poison Ivy

A number of people suffer after coming into contact with poisonous plants such as poison ivy, poison sumac and poison oak, every year. The ICD-10-CM code for such contact is:

  • L23.7: Allergic contact dermatitis due to plants, except food

ICD-10-CM L23.7 is grouped within Diagnostic Related Group(s) (MS-DRG v36.0):

  • 606: Minor skin disorders with MCC
  • 607: Minor skin disorders without MCC

In some cases, the dermatitis may spread and cause significant issues like skin infections. Using additional ICD-10-CM codes for the infections or other issues documented may help support reporting a higher-level E/M code or procedure code for the specific encounter. The codes are:

  • L00-L08: Infections of the skin and subcutaneous tissue
  • L10-L14: Bullous disorders
  • L20-L30: Dermatitis and eczema
  • L40-L45: Papulosquamous disorders
  • L49-L54: Urticaria and erythema
  • L55-L59: Radiation-related disorders of the skin and subcutaneous tissue
  • L60-L75: Disorders of skin appendages
  • L76-L76: Intraoperative and postprocedural complications of skin and subcutaneous tissue
  • L80-L99: Other disorders of the skin and subcutaneous tissue

ICD-10-CM codes for Swimmer’s Ear

Another common warm weather disease is swimmer’s ear, also known as Otitis externa or external otitis, which is an inflammation of the outer ear and ear canal. The inflammation can be secondary to dermatitis (eczema) only, with no microbial infection, or it can be caused by active bacterial or fungal infection. In either case, but more often with infection, the ear canal skin swells and may become painful or tender to touch. The codes to document this illness are

  • H60.33: Swimmer’s ear
    • H60.331: Swimmer’s ear, right ear
    • H60.332: Swimmer’s ear, left ear
    • H60.333: Swimmer’s ear, bilateral
    • H60.339: Swimmer’s ear, unspecified ear

ICD-10-CM codes for Heat Stroke

The least common but most severe heat-related illness is heat stroke. The ICD-10-CM index has a long list of subentries under “Heat (effects).” Most of them fall under T67.- Effects of heat and light, though there are a few exceptions. The four-character subcategories under T67.- in ICD-10-CM 2019 are:

  • T67.0– Heatstroke and sunstroke
  • T67.1– Heat syncope
  • T67.2– Heat cramp
  • T67.3– Heat exhaustion, anhydrotic
  • T67.4– Heat exhaustion due to salt depletion
  • T67.5– Heat exhaustion, unspecified
  • T67.6– Heat fatigue, transient
  • T67.7– Heat edema
  • T67.8– Other effects of heat and light
  • T67.9– Effect of heat and light, unspecified.

Currently, T67.0- divides into three codes that differ based only on encounter type (initial, subsequent, sequela). When ICD-10-CM 2020 becomes effective on October 1, 2019, those options will expand to give you these more specific codes:

  • T67.01XA: Heatstroke and sunstroke, initial encounter
  • T67.01XD: Heatstroke and sunstroke, subsequent encounter
  • T67.01XS: Heatstroke and sunstroke, sequel
  • T67.02XA: Exertional heatstroke, initial encounter
  • T67.02XD: Exertional heatstroke, subsequent encounter
  • T67.02XS: Exertional heatstroke, sequel
  • T67.09XA: Other heatstroke and sunstroke, initial encounter
  • T67.09XD: Other heatstroke and sunstroke, subsequent encounter
  • T67.09XS: Other heatstroke and sunstroke, sequela.

According to a note under that subcategory in the ICD-10-CM 2020 tabular list available on the CDC ICD-10-CM site, the Subcategory T67.01- will be appropriate for heat apoplexy, heat pyrexia, siriasis, and thermoplegia. And beyond T67.- codes, the index subentries under “Heat (effects)” that don’t fall under T67.- include these conditions:

  • Burn
    • L55.9: Sunburn, unspecified
  • Dermatitis or eczema
    • L59.0: Erythema ab igne [dermatitis ab igne]
  • Prickly or rash
    • L74.0: Miliaria rubra.

Knowing the highly specific ICD-10 codes related to documenting warm weather diseases such as insect bites, poison ivy, swimmer’s ear and heatstroke is important for healthcare providers. For more efficient and reliable coding, physicians can consider services from outsourced medical billing companies, as experienced coders in such firms will be familiar with all applicable codes and can assign the right ones.

Medical Coding Tips for Sleep Medicine

Medical Coding Tips for Sleep Medicine

Sleep is essential for both our physical and mental health, but very few seem to realize how important it really is. Health consequences from sleep disorders and tiredness are shocking and it is apparent that there is a significant amount of sleep issues in our society. According to the CDC, 35% of adults don’t get enough sleep (7 hours per day). Not getting enough sleep can lead to sleeping deprivation and related disorders. Occasional sleeping problems might affect some people, but then it is important to find out if it’s just a minor, passing annoyance or a sign of a more serious sleep disorder or underlying medical condition. According to the American Sleep Association (ASA), 50-70 million US adults have a sleep disorder. Sleep medicine physicians treating patients have to maintain accurate documentation regarding the diagnosis and medical services provided. Medical coding for sleep medicine is quite challenging, as there are several rules related to reporting the procedures accurately. Relying on a reliable medical billing company can help in accurate and timely claim submission for appropriate reimbursement.

ICD-10 Diagnostic Codes for Sleep Disorders

  • G47.00: Insomnia (NOS)
  • G47.10: Hypersomnia (NOS)
  • G47.33: Obstructive Sleep Apnea
  • R06.83: Snoring
  • G47.20: Circadian Rhythm Sleep Disorders (NOS)
  • G47.21: Delayed Sleep Phase Type
  • G47.22: Advanced Sleep Phase Type

Procedure Codes for Sleep Medicine

Procedure codes for sleep medicine are contained in the CPT® code range 95803-95783 and HCPCS Level II code range G0398-G0399. Code sets can be categorized further by type:

  1. Miscellaneous sleep diagnostic testing
  2. Home sleep study tests
  3. Sleep studies
  4. Polysomnography
  1. Miscellaneous Sleep Diagnostic Testing: In this type, there are two different tests that can be performed, they are:
    • 95803: Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)
    • 95805: Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness

      95803 is a home setting test, where patients are given an actigraph device to wear on the wrist. This device records sleep and movements over 3 to 14 days. Once the device is returned to the provider’s office, the data can be downloaded to a computer and analyzed by specialized software to assist in the evaluation or monitoring of sleep disorders such as circadian rhythm disorders and sleep-disordered breathing.

      The second test, 95805 is a multiple sleep latency test. This testing consists of 4 or 5 short nap opportunities in the office setting that are set a few hours apart. The patient’s brain waves, muscle activity, and eye movements are monitored and recorded during these nap sessions. That data can be used to diagnose narcolepsy and excessive daytime sleepiness, as well as assess the efficacy of treatments for breathing disorders. If fewer than 4 nap opportunities are recorded, append modifier 52 for Reduced services.

  1. Home Sleep Studies: This is a cost-effective test that is performed at the patient’s home. A special piece of equipment tracks breathing, oxygen levels, and breathing effort overnight and this data is abstracted from the device and is interpreted with specialized software to diagnose sleep disorders. Generally, there are three HCPCS Level II codes to report home sleep study tests, with the differentiating factor being the number of channels used during recording:

    • G0398: Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
    • G0399: Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation
    • G0400: Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels
    • CPT® code range 95806-95783 contains codes for all in-office/hospital sleep studies. These are either sleep studies or Polysomnographies (specialized sleep studies).

      For instance,

    • 95806: Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement)
    • 95807: Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
    • 95808: Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
    • 95810: Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
  1. Sleep Studies (Non-polysomnographic): These sleep studies are further categorized into two types: attended or unattended.

    Only one CPT® code for an attended, non-polysomnographic sleep study

    • 95807: Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
    • Unattended, non-polysomnographic sleep studies are reported using three CPT® codes:

    • 95806: Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement)
    • 95800: Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time
    • 95801: Minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone)
  1. Polysomnography: Special types of in-office/hospital, attended sleep studies that record brain waves, blood oxygen levels, heart rate, breathing, eye movements, and leg movements. This test can either be purely diagnostic, therapeutic, or “split.”

    The three codes for Purely Diagnostic Polysomnography are:

    • 95808: Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
    • 95810: Age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
    • 95782: Younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist

    For patients with a diagnosis such as sleep apnea, Therapeutic and Split Polysomnography can be used, because its purpose is to determine what titration levels of therapies, such as continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP), are required to treat the patient’s apnea.

    Two codes are used to report therapeutic and split Polysomnography:

    • 95811: Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist
    • 95783: Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist

According to the American Academy of Sleep Medicine (AASM), to report apolysomnography (PSG) and home sleep apnea test (HSAT), there has to be continuous & simultaneous monitoring & recording of various physiological & pathophysiological parameters of sleep for 6 or more hours. Similarly, for codes 95782 and 95783 (pediatric polysomnography and PAP titration) a minimum of 7 or more hours of monitoring and recording is required. The reduced services modifier, modifier 52, must be used in cases involving less than 6 hours recording time in patients ages 6 and older and in cases involving less than 7 hours recording time in patients under age 6.

With all the challenges involved, the best option for sleep medicine physicians is to rely on specialized outsourced medical billing services for timely and accurate claim submission. Expert teams in an established outsourcing company can handle all the billing and coding challenges competently and help healthcare providers maximize their revenue and improve patient care.

Injection and Infusion Coding – Tips to Overcome Common Challenges

Injection and Infusion Coding – Tips to Overcome Common Challenges

Coding for the administration of injections and infusions involves many challenges due to extensive CPT instructional notes, hierarchy rules, and differing payer guidelines. Outsourced medical billing can ease the confusion around reporting drug administration services. Here are 7 tips to overcome common challenges in this area.

  • Understand the terms: Current Procedural Terminology (CPT) defines the terms “injection” and “infusion” as follows:
    • Injection-delivers a dosage in one “shot,” rather than over a period of time; may be administered by various routes, including subcutaneous, intramuscular, intraarterial, and intravenous

An injection is medication administered for an immediate effect (typically within 3-5 minutes) is an injection.

    • Infusion-administration of intravenous fluids and/or drugs over a period of time for diagnostic or therapeutic purposes

An infusion is a medication or solution that is administered via saline or other solutions and given over a period of time (usually 30 minutes or more).

  • Understand the basic hierarchies: Hierarchies make infusion billing complex. There are hierarchies for medication type and route of administration.
    • Medication type/service level:
      • Chemotherapy or other biologic agents/complex drugs – Chemo includes highly complex drugs or biologic agents
      • Hydration – re-packaged fluids and electrolytes
      • Therapeutic, prophylactic and diagnostic substance – administration of drugs and other substances (other than hydration)
  • Infusion categories and route : Infusions differ based on route and method of administration. The three broad types of infusion/injection services that practices provide are:
    • Intravenous Infusions (IV) – Administration within or into a vein or veins.
    • Intravenous Pushes (IVP) – This involves rapid intravenous injection (push) using a syringe. It is usually given over a period of less than 15 minutes without the aid of an electronic or manual external pump.
    • Injections (Sub-Q, IM) – The Sub-Q injection involves using a short needle to injecta drug into the tissue layer between the skin and the muscle. The IM injection is direct injection of a medication into the muscle of a patient.

There are multiple codes for IV push and the code selected would be based on whether the push is initial or not as well as the time that passes between multiple pushes of the same non-chemotherapeutic substance or drug. Hydration services and therapeutic infusions (chemotherapy and non-chemotherapy) have their own distinct coding rules.

  • Know the time criteria: Time must be documented correctly in the medical record to assign the codes for infusion/injection administration services. Documentation must specify at what time each substance was administered and total infusion time. The infusion time is the actual time over which the infusion is administered. Best practice is to document Start and Stop times for all drugs/substances. Time is always billed by the hour. For the first hour, the infusion must be at least 16 minutes (greater 15mins) to meet the requirements for the first hour of infusion. Anything less than 16 minutes is regarded an Intravenous Push (IVP).
  • Initial, Sequential/Subsequent, or Concurrent: It must be specified is a drug or substance administered is Initial, Sequential/Subsequent, or Concurrent.
    • Initial: To code initial administration, hierarchy must be utilized. Only one initial code is used per encounter
    • Sequential/Subsequent: This refers to the infusion of a different drug than primary. It must be given prior to or after other drugs (not considered concurrent).
    • Concurrent: This refers to infusions of new substances or drugs at the same time as another substance or drug. Concurrent service is only allowed once per encounter.

In the physician practice, the initial service is the primary reason for the visit. AAPC provides the following example to illustrate this: a patient who comes in for chemotherapy also gets an antibiotic injection and a hydration infusion. The chemotherapy is the initial service as it is the primary reason for the visit. In the outpatient facility setting, the initial service is determined based on its ranking in the hierarchy levels. Chemotherapy is has the topmost rank, followed by non-chemotherapy agents and hydration.

  • Ensure compliance: AHIMA points out that audits by governmental agencies and third-party payers increasingly focus on units of service reporting in injection and infusion coding. Proper knowledge of the National Correct Coding Initiative edits and injection and infusion coding can help avoid negative audit results. AHIMA provides various tips to mitigate compliance concerns such as adhering to CPT coding rules, thorough documentation, resolving edits, periodical internal and external audits, etc.
  • Know the current CPT codes: The 2019 CPT codes for injections and infusions are as follows:
    • Hydration 96360 ‐ 96361
    • Therapeutic, Prophylactic, Diagnostic 96365 – 96379
    • Chemotherapy (Anti‐neoplastic agents, Biological response modifiers, Monoclonal antibodies) 96401 ‐ 96549

Coders should also be knowledgeable about modifier use.

  • Ensure comprehensive documentation: Documentation to report infusion/injection administration requires the following elements:
    • Detailed Physician Order including: Medical condition necessitating the medication ordered, medical condition necessitating the need for hydration (if ordered), name of drug, dosage, length and route of administration, and frequency of administration
    • Medication Administration Record
    • Nursing documentation

Selection of injection and infusion codes is a demanding aspect of outpatient coding. In addition to being knowledgeable about various terms, a thorough understanding of guidelines provided by the American Medical Association (AMA) is necessary for accurate coding. Outsourced medical billing companies have AAPC-certified coders who are knowledgeable about the nuances of reporting infusion/injection services. Partnering with an experienced company can ensure success with coding and prevent denials.

November Is National COPD Awareness Month

November Is National COPD Awareness Month

COPD AwarenessEvery year November is observed as National COPD Awareness Month. Chronic obstructive pulmonary disease (COPD) is a chronic condition in which the airways become damaged, leading to restricted oxygen access to the lungs. The condition is most often caused by long-term exposure to gases or particulate matter, most commonly cigarette smoke. Although there is no cure for this life-threatening disease, early diagnosis, education, and treatment can slow its progression. The National Heart, Lung, and Blood Institute (NHLBI) reports that an estimated 15 million Americans suffer from COPD, and several additional millions likely have COPD and don’t even know it. Early diagnosis and treatment can help people with COPD improve their quality of life and health. Outsourced medical billing helps pulmonary specialists to focus on treating these patients than wasting valuable time on their documentation tasks.

The risk factors of COPD can be increased by smoking tobacco, secondhand smoke, air pollution, alpha-1 antitrypsin deficiency and a few other conditions. While the symptoms include cough, chest discomfort, shortness of breath, and wheezing, progressive or more serious symptoms may include respiratory distress, tachypnea, cyanosis, use of accessory respiratory muscles, chronic wheezing, abnormal lung sounds, prolonged expiration, elevated jugular venous pulse, and cyanosis.

Tests to diagnose the condition include Chest X-rays and CT scan of the lungs. A person diagnosed with chronic obstructive pulmonary disease (COPD) may have any one or both of these chronic lower respiratory diseases such as Emphysema and Chronic bronchitis.

Although lung damage is irreversible, therapies that can improve the quality of life include Bronchodilator, Medication, Pulmonary rehabilitation, Oxygen and Surgery. When it comes to reimbursement, Medicare covers pulmonary rehabilitation for moderate to severe COPD. Pulmonary function tests (PFTs) measure the mechanical ability to move air in and out of the lungs and the effectiveness of getting oxygen into, and carbon dioxide out of, the body.COPD
Based on the Global Initiative for Chronic Obstructive Lung Disease program (GOLD), the staging of COPD is done as follows

1 – Very mild COPD with an FEV1 (forced expiratory volume in one second) – 80 percent or higher of normal. Reduced airflow often goes unnoticed
2 – Moderate COPD with an FEV1 between 50 and 80 percent of normal. Chronic coughing, wheezing, and shortness of breath are symptoms.
3 – Severe emphysema with FEV1 between 30 and 50 percent of normal. Symptoms worsen and may affect normal activity.
4 – Very severe, or “end stage,” COPD with a lower FEV1 than stage 3, or has stage 3 FEV1 and low blood oxygen levels. Lung function gets worsen to life-threatening levels.

While this whole month is dedicated to COPD awareness, this year’s World COPD Day is on November 15. All those interested in raising COPD awareness can host events, lead discussions, and thus help people across the country take the first step toward improving the lives of those with COPD.

Pulmonary doctors must submit medical claims with accurate medical codes to get reimbursement on-time. Medical coding companies with long-term experience in the field can help physicians with accurate coding.

Our next blog on COPD medical coding will help you get a clear idea on assigning the right codes for this condition.