Receive Proper Reimbursement for Pulmonary Function Studies by Following CMS Guidelines

Claims for pulmonary function studies are regularly rejected because of failure to establish medical necessity and/or to conform to the indications and limits of coverage. And, proposed Correct Coding Initiative (CCI) edits have created confusion as to when and how allergists may bill pulmonary function tests in addition to E/M services provided on the same date of service. If you review and follow the CMS and Medicare guidelines below, however, claims will receive proper reimbursement.

Spirometry Codes and Indications

Pulmonary function testing provides information as to the physiology of ventilation, mechanical abnormalities in respiration, and elements of gas diffusion for patients with breathing difficulties or other specified conditions. Generally, simple spirometry which measures the volume and flow rate of expired air is sufficient to differentiate obstructive and restrictive disorders and determine their severity.

Applicable CPT codes include:
 

94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation
 

94014 Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission of spirometric tracing, data capture,  analysis of transmitted data, periodic recalibration and physician review and interpretation
 

94015 recording (includes hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic recalibration)
 

94016 physician review and interpretation only
 

94060 Bronchospasm evaluation: spirometry as in 94010, before and after     bronchodilator (aerosol or parenteral).

Code 94010 defines the basic test, while 94060 describes the test performed before and after bronchodilator administration. Codes 94014-94016 refer to the patient-initiated spirometric recording per 30-day period and are used to diagnose and monitor the progress of the patient with upper and lower respiratory disease and related problems.
 
When appropriate, allergists may also use the following:
 

94070 Prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics
 

94375 Respiratory flow volume loop.

Local medical review policies (LMRPs) for Medicare carriers nationwide specify minimum indications to establish medical necessity for use of pulmonary function test codes, which may include any of the following:
 

 to identify the cause of a significant symptom such  as cough
 

 to assess breathing in a patient who has a condition that might affect breathing such as muscular dystrophy
 

 to guide the initiation of therapy
 

 to assess the effect of therapy
 

 to assess breathing capacity preoperatively 
 

 to monitor a patient who is taking a drug that might cause respiratory side effects.

To further establish medical necessity, you must include an approved diagnosis with claims. Payers generally accept a wide range of ICD-9 codes for [...]

- Published on 2002-03-01