Pediatric Coding Alert

Don’t let bundling, modifier use obstruct your documentation.

With all their confusing terminology and bundling issues, it’s no surprise that pulmonary function testing (PFT) and treatment are subject to plenty of coding myths. This means there are plenty of ways you can be confused when you code them.

That’s why we assembled four of the most common pulmonary testing and therapy myths and dispelled them, so you can catch your breath and report these vital pediatric services with confidence and accuracy.

Myth 1: You Can Report Measurement and Volume Separate From Spirometry

This myth stems from confusion between CPT^® guidelines and National Correct Coding Institute (NCCI, or just CCI) rules regarding Procedure-to-Procedure (PTP) edit pairs.

The CPT^® guidelines that accompany the Pulmonary Diagnostic Testing and Therapies are very specific that various procedures to measure vital lung capacity and volume are included in spirometry procedures. “Code 94150 [Vital capacity, total (separate procedure)] is bundled into 94010 [Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation], 94200 [Maximum breathing capacity, maximal voluntary ventilation], and 94375 [Respiratory flow volume loop],” JoAnne M. Wolf, RHIT, CPC, CEMC, AAPC Fellow, coding manager at Children’s Health Network in Minneapolis, Minnesota, reminds coders.

“Codes 94150, 94200 and 94375 also have a parenthetical statement that instructs you not to report them in conjunction 94010 [Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation] or 94060 [Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration],” Wolf adds.

“In addition, NCCI PTP edits bundle 94150, 94200, or 94375 into 94010 or 94060,” Wolf continues. However, “codes 94150 and 94200 do have a 1 listed in the modifier indicator column, indicating that use of a modifier may be appropriate. But modifier 59 [Distinct procedural service] would only be appropriate if your provider performed the lung capacity/volume measurement in a separate encounter. If performed together, then the billing and use of the modifier would not be appropriate. And code 94375 has a 0 in the modifier column, indicating that a modifier would never be considered appropriate,” Wolf clarifies.

Two other, more specialized tests can also be billed separately from spirometry. “Codes 94726 [Plethysmography for determination of lung volumes and, when performed, airway resistance] and 94727 [Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes] can be separately billed per CPT^® guidelines,” adds Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

Myth 2: Component Modifiers Must Always Be Appended to Respiratory Tests

“Codes 94010, 94060, 94150, 94200, and 94375 have a technical and professional breakout according to the Medicare Fee Schedule Database [MFSDB]. When a CPT^® service is defined by the MFSDB as having a professional and technical component, the definition allows for the billing of a portion a CPT^® code with the use of modifier 26 [Professional component] and TC [Technical component],” explains Wolf.

However, this does not mean that you have to append one, or both, of the modifiers to any of the codes. “The rule is, if a code has both a TC and 26 component, you only report these modifiers when your practice solely interpreted the test results or only administered the test but without interpretation,” Witt notes. “If your practice owns the equipment, and your provider interprets the results, you report the code with no modifier. The relative values for the TC and 26 modifiers equal the total RVUs for the unmodified code,” Witt elaborates.

Myth 3: Respiratory Tests Are Only Diagnostic and Cannot Be Therapeutic

Actually, there is one test that can function as both a diagnostic test and a treatment. As its descriptor states, 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) can be used for both purposes.

Coding caution: Code 94640 should only be used for a single treatment lasting less than an hour. You should report any subsequent treatments by appending modifier 76 (Repeat procedure or service by same physician or other qualified health care professional). And don’t forget to keep your eye on the clock and report 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour) for services that go beyond a full hour and +94645 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour (List separately in addition to code for primary procedure) in conjunction with 94644 for each additional hour.

Myth 4: You Can Report Equipment Demonstration and Treatment Together

This final myth is a tricky one. If your provider or clinical staff member demonstrates a nebulizer and you code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device), the service is considered bundled into 94640. However, you can separate the bundle providing you can document (a) that the two services occurred at separate times or (b) that the treatment and demonstration involved the use of different devices. If either is the case, you will need to append modifier 59 to the 94664 when it is the column 2 code to 94640.