ED Coding and Reimbursement Alert

Using modifier -26 (professional component) and documenting interpretation are key to optimizing reimbursement for brochospasm evaluations.

A device called a spirometer is used by the ED clinician to measure the amount of air entering and leaving the lungs. Code 94060 is for bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator (aerosol or parenteral).

Several groups have reported receiving denials when using 94060 because the procedure is a diagnostic test and the ED physician does not own the equipment. We dont report it among our charges, says Michelle Goatley, CPC, specialist in the coding department of Innovative Management Alternatives in Virginia Beach, Va. This question has come up before for one of our family practice doctors, and we determined that he couldnt bill for it. It is included in the evaluation and management (E/M) code.

Codes 94010-94799 are listed under the Medicine, Pulmonary section of CPT 2000. According to the introduction to that section: Items 94010-94799 include laboratory procedure(s) and interpretation of test results. If a separate identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported in addition to 94010-94799.

Because the codes include both the test and the interpretation, the physician should not get paid for the technical component (the actual performance of the test) unless he or she actually owns the equipment, says Jan Loomis, director of coding and documentation for TeamHealth West Inc., an emergency physician staffing company based in Pleasanton, Calif. But you can charge for the interpretation performed by the emergency physician if you bill code 94060 with a -26 modifier.

The modifier will indicate to the payer that you are seeking reimbursement only for performing the interpretation of the test results. If you bill it without the modifier, the carrier can only assume that it includes both components, she explains.

Documentation of Interpretation Required

The bronchospasm evaluation is done pre- and post-medication, Loomis explains. The chart documentation to look for in order to report the code would be a statement by the emergency physician that he or she performed this service rather than the respiratory therapist. The pre- and post-medication results should be documented.

According to CPT, performance of spirometry includes the graphic record, the total and timed vital capacities, and the expiratory flow rate measurements. If the respiratory therapist performed the spirometry test and interpretation and the attending physician uses this data to make treatment decisions, then, as Goatley advises, the physician can use this information only as part of the medical decision-making required for a particular E/M level.