The keys to successful coding and billing result from thorough documentation and proper coding of the visit or procedure performed. It is critical to document what work was actually conducted during a patient encounter.This documentation will justify the Current Procedural Terminology^® (CPT) code used and the level of evaluation and management (E/M) service billed. Documentation is necessary for procedures, as well as E/M services, and it is important that a complete description of what was accomplished during the procedure is documented.

Daily, we use two coding systems when we bill for patient encounters. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9- CM) system is used to describe the diagnosis, symptoms or findings for each patient. The ICD-9-CM codes provide the medical necessity for billing the CPT codes.The CPT codes are used to define the care given, the level of intensity, and which procedures were performed.

There are three manuals that are essential to help with coding.These are:

• Current Procedural Terminology 2006, published by the AMA;
• 2006 Professional ICD-9-CM for Physicians, published by Ingenix; and
• Appropriate Coding for Critical Care Services and Pulmonary Medicine: A Practice Management Tool, published by the American College of Chest Physicians.

These publications are absolutely essential for one to understand coding and billing. If one is interested in physician reimbursement, The Essential RBRVS, published by Ingenix, is an excellent reference.

Examples of ICD-9-CM codes used by pulmonologists would be:

• 492.8 (emphysema);
• 493.90 (asthma);
• 491.20 (obstructive chronic bronchitis without exacerbation);
• 786.05 (shortness of breath);
• 786.3 (hemoptysis); and
• 786.50 (unspecified chest pain).

These codes must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reasons for the patient encounter procedure or visit. If no definitive diagnosis can be made, codes for symptoms or signs are acceptable.‘Rule out’ conditions must not be coded.You should code only documented diagnoses or signs and symptoms. ICD-9-CM codes are updated twice a year in April and October.