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 short of breath. 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, where x represents the circumstances where the patient acquired the damage), an allergist orders several pulmonary function tests (PFTs), including spirometry (94010), flow volume loop (94375), lung volume (94240), diffusing capacity (94720), 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.

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 (94240, Functional residual capacity or residual volume; helium method, nitrogen open circuit method, or other method) and diffusing capacity (94720, Carbon monoxide diffusing capacity [e.g., single breath, steady state]).

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), says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

"However, you can report the entire service (94070, 95071) if these PF tests are performed in the allergist's privately owned PF laboratory," he says.

Important: Apply the same service-locale coding to 94240 and 94720 as well. "Allergists report 94240-26, 94720-26 in a facility setting; 94240, 94720 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 National 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," Plummer says. 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," he adds.

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
• 94720
• 94240.

Keep in mind: Some payers may require modifier 25 on the E/M service, as they apply a global on the xxx global day services similar to one found on a zero day global. So, if you are finding it difficult to get paid for the E/M and the services, and the documentation supports a significantly separately identifiable EM, report the EM with modifier 25.

In a facility setting, the allergist should bill the professional components of 94070, 94720 and 94240. The facility reports the technical portion of the codes listed above and also bills for the antigen test with 95071.