Otolaryngology Coding Alert

Hint: 94010, 94375 are shoe-ins for bundled status.

A workup for possible extrinsic allergic alveolitis (EAA) doesn’t have to leave you reaching for headache medicine. Follow these steps to sort out which codes you should bill and which you should omit.

When a patient has a Type III allergic reaction to environmental allergens and develops local inflammation that causes tissue damage, the allergist should diagnose the patient as having a common occupational antigen disease--hypersensitivity pneumonitis, an inflammatory lung disorder that is often referred to as extrinsic allergic alveolitis.

The steps that an allergist must take to properly diagnose this disease, however, can lead to complicated coding issues. Several tests that the allergist may order can be useful in diagnosing EAA. See if you can solve this coding conundrum:

To test a patient for EAA (495.x), an allergist orders several pulmonary function tests (PFTs), including spirometry (94010), flow volume loop (94375), lung volume (94726/94727), diffusing capacity (94729), and pulse oximetry (94760). He also orders an antigen challenge test (94070, 95071) and a blood workup (86001, 85025). Should I separately report the tests, or are some bundled into each other?

Step 1: Report Performed E/M Service

You should code for the appropriate level of E/M care documented, if provided. Taking into account the in-depth history, examination and level of medical decision-making involved in working up a possible diagnosis of hypersensitivity pneumonitis or EAA, "if documented correctly a higher-level office visit (such as 99204 or 99214) may be warranted for this extensive work," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

Remember: You cannot bill pulse oximetry (94760) on the same day that you bill a physician-performed E/M service--94760 would be bundled into the E/M service.

Step 2: Let the Lab Code for Its Work

You cannot bill for the laboratory tests (86001, 85025) "unless your office is certified to process and analyze the specimens," Pohlig says. But you can report some of the other tests in addition to the E/M visit, such as postexposure evaluation (94070, Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents [e.g., antigen(s), cold air, methacholine]), antigen challenge testing (95071, Inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with antigens or gases, specify), lung volume (94726/94727, Plethysmography for determination of lung volumes and, when performed, airway resistance/Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes) and diffusing capacity (94729, Diffusing capacity [e.g., carbon monoxide, membrane) (List separately in addition to code for primary procedure]).

Step 3: Check Site Before Billing PFTs

If the allergist saw the patient in the outpatient portion of the hospital, and the prolonged postexposure evaluation (94070) and antigen challenge test (95071) were performed in the hospital PFT lab, the allergist may only report the professional component(s) of the service (94070-26).

The facility-managed lab reports the technical components (94070-TC, 95071). However, you can report the entire service (94070, 95071) if these PF tests are performed in the allergist’s privately owned PF laboratory.

Important: Apply the same service-locale coding to 94726/94727 and 94729 as well. "Allergists report 94726-26/94727-26, 94729-26 in a facility setting; 94726/94727, 94729 in an office setting," Pohlig says.

Step 4: Nix 94375 Due to 2 Bundles

Although the Physician Fee Schedule designates 94375 (Respiratory flow volume loop) as status "A," you should not bill for the procedure in this scenario. Status A means the procedure is payable, unless the Correct Coding Initiative (CCI) bundles it with other services performed on the same day. In this case, 94375 is subject to two edits.

Bundle 1: Medicare will not pay for both 94010 and 94375. Code 94375 (Respiratory flow volume loop) is considered a component of 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation).

You will have to check with non-Medicare insurance carriers to determine if they will allow payment for 94010 and 94375 billed on the same day.

Bundle 2: "CCI also bundles 94375 into 94070, and cannot be reported unless it was performed independently for a separate reason," Pohlig says.

Step 5: Reserve 94010 for Separate Test

You should not report 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) because CCI bundles it into the more-comprehensive 94070 code. The only time you would report this code separately is when the allergist orders spirometry for a separate and distinct reason. For example, if 94010 is the first test done, and it indicates a problem that requires additional testing with the prolonged postexposure test (94070), you would code this scenario as 94070, 94010-59 (Distinct procedural service).

Step 6: Compare Your Answer to This List

Summary: For the scenario above in a nonfacility setting, the allergist reports the highest-valued procedure first and lists the other procedures next:

• 992xx
• 94070
• 95071
• 94729
• 94726/94727.

Some payers may require modifier 25 for a significant and separately identifiable E/M service with the 992xx. Although the xxx global days associated with the above codes should not require modifier 25, CCI quite a few years ago added to the narrative that you should consider xxx global days to have a very small E/M service associated with them, as defined for minor procedures. So if a payer adopts this definition, the provider will need to use modifier 25 to indicate that the E/M is beyond any small E/M service associated with the xxx global period services. This will also mean the documentation of the E/M will need to demonstrate that the E/M service is above and beyond the very small E&M service defined for minor and xxx global services.

In a facility setting, the allergist should bill the professional components of 94070, 94729 and 94726/94727. The facility reports the technical portion of the codes listed above and also bills for the antigen test with 95071.