Internal Medicine Coding Alert

You're having trouble choosing the correct code for a pulmonary function test (PFT) (94010-94799) when the internist diagnoses emphysema (492.0-492.8). Right? If so, it's time for an update on PFT bundling basics. Coding experts offer the following three tips on PFT code selection to enhance your reimbursement for these tests.
A patient with emphysema, a form of chronic obstructive pulmonary disease (COPD, 496), often presents to the office with a variety of symptoms, including shortness of breath (786.05), wheezing (786.07), breathlessness (786.09), renal insufficiency (593.9), and congestive heart failure (428.0).
 
After the patient presents to your internist with symptoms like wheezing and renal insufficiency, your physician performs numerous in-office tests to properly diagnose the disease, including PFTs (94010-94799) and chest x-rays (70010-76499), says Judy Richardson, RN, MSA, CCS-P, a senior consultant at Hill and Associates, a coding and compliance consulting firm in Wilmington, N.C. You should report codes for the presenting symptoms until your physician diagnoses emphysema. Once your internist lists emphysema, however, you should report the appropriate diagnosis code, such as 492.0, she says.

1. Know 94010 and 94060 Bundling Rules

 When your internist suspects that a patient has emphysema, make sure you're prepared to code the tests involved. Your physician will perform either a spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) or a bronchospasm evaluation (94060, Bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]).
 
The bronchospasm evaluation involves spirometry (94010) taken before and after your physician administers a bronchodilator (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]) to dilate the airways.
 
Remember that you cannot report both spirometry and bronchospasm tests on the same day - the National Correct Coding Initiative bundles 94010 into 94060. NCCI also bundles several other tests with 94060, including 94375 (Respiratory flow volume loop), 94200 (Maximum breathing capacity, maximal voluntary ventilation), 94770 (Carbon dioxide, expired gas determination by infrared analyzer), 94640, and 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).
 
If your internist performs the test in the office, you may bill for the bronchodilator medication, such as Albuterol (J7618). But when a physician performs these tests in a hospital or other outpatient facility, you cannot bill for the supplies because the facility delivers them, says Antoinette Revel, CPC, a coding expert and nurse practitioner for Healthcare Consulting Services in Warrington, Pa.

2. Unbundle Stress Tests From Spirometry

Be prepared with the proper codes when your internist orders a number of other diagnostic tests and PFTs. He or she can order a chest x-ray and diffusing capacity test, such as 94720 (Carbon monoxide diffusing capacity [e.g., single breath, steady state]). Also, your physician may request a lung volume test 94260 (Thoracic gas volume) or 94350 (Determination of maldistribution of inspired gas: multiple breath nitrogen washout curve including alveolar nitrogen or helium equilibration time). But Medicare considers these PFTs bundled with spirometry.
 
Depending on the emphysema's severity, your internist may order pulse oximetry 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination) and blood gas testing (82803-82810). Although you may be tempted to bill for these procedures, remember that Medicare considers pulse oximetry as incidental and includes the service in the E/M visit.
 
You should submit 94760 to Medicare only if your physician did not perform any other service on the patient that day, Richardson says. For example, a physician checks a pulse's oximetry on a patient who presents with severe chest pain (786.50) and administers no other tests or services that day.
 
You could encounter coding complications if your internist decides to perform a pulmonary stress test. For example, your physician administers a stress test, which you code as 94620 (Pulmonary stress testing; simple [e.g., prolonged exercise test for bronchospasm with pre- and post-spirometry]), but your carrier may consider spirometry (94010) bundled with this service, Revel says. In that case, append modifier -59 (Distinct procedural service) to differentiate the stress test from the initial spirometry.
 
Suppose your physician sees a 65-year-old woman who has dyspnea (786.0x) and cough (786.2) after she walks several city blocks. Both her stress test and spirogram come back normal. As she walks on the treadmill, dyspnea occurs, and your physician obtains a repeat spirogram to evaluate the patient for exercise-induced bronchospasm. Even though the original spirometry tested normal, the patient showed bronchospasm symptoms, which may establish medical necessity to unbundle the service, Richardson says. But you should attach a copy of the patient's records to the claim and prepare yourself for an appeal, she adds.
 
If your physician does not own the PFT equipment, you should append modifier -26 (Professional component) to 94010 or 94060 for your physician's interpretation of the test results. You can only report these codes without modifier -26 if your internist both owns the equipment and interprets the results.

3. Report 99215 for Treatment Consults

Because your internist can increase his or her level of medical decision-making when testing a patient for emphysema, you may be able to code for a higher level of E/M service. But remember that if your internist is treating an established patient, your physician must meet two of the three components: history, exam and decision-making, Revel says. And if your physician's patient is new, your physician must meet all three requirements.
 
For example, your internist's established patient, who's a heavy smoker, complains of chest pains (786.5x) and wheezing (786.07). Because your physician must determine the emphysema's severity, develop a treatment plan, run various tests and interpret results, you could report 99214 (Office or other outpatient visit). In addition to fulfilling two of the three E/M components, if your physician consults with a pulmonologist because the patient's symptoms have worsened and may require your physician to transfer care or treatment concerns, you could report 99215.
 
Make sure your physician's documentation supports a 99215, Richardson says. Your physician should document each step he takes in treating the patient. For instance, your physician should describe how he will treat the patient's chest pains and wheezing, and which tests he performed to determine the emphysema's severity. Medicare does not bundle these PFTs with spirometry.