Primary Care Coding Alert

Family physicians (FPs) often perform spirometry (94010) and bronchospasm (94060) tests on patients with respiratory problems. Combined with other pulmonary function test (PFT) codes, office visits and complex treatments, they present a number of challenges. To optimize reimbursement for these commonly performed tests, coders must know how the tests work with one another and how they affect billing when combined with other procedures.
 
Knowing exactly what the spirometry and broncho-spasm tests are will help coders understand why theyre bundled, says Kathy Pride, CPC, CCS-P, HIM application specialist with QuadraMed, a national healthcare information technology and consulting firm based in San Rafael, Calif. There are still practices that try to code these separately, but the bronchospasm evaluation includes spirometry, so theyre always denied.
 
A spirometry measures lung volume and function (the rate at which you blow air in and out). The patient blows into a tube hooked up to a sensor that calculates the measurements. An FP performs spirometry to help diagnose chronic obstructive pulmonary disease (COPD) and to check on asthmatic patients and patients with shortness of breath. Coders bill spirometry with 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation).
 
The bronchospasm test is almost identical to spirometry. First, a spirometry test is performed, then the physician would administer a bronchodilator to dilate the airways, after which another spirometry would be done. The bronchodilator is typically in aerosol form (such as an albuterol inhaler) and helps determine if the patient has reactive airways. Coders should use 94060 (Bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]) to report bronchospasm tests. 

 
The following case studies illustrate how to code for these PFTs:
 
Scenario #1: A 65-year-old new patient who has been smoking for 45 years presents with shortness of breath. The FP performs a detailed history and an expanded problem-focused exam, and decides that spirometry would help diagnose COPD. The patient has decreased readings on the first spirometry, so the physician uses albuterol and readministers the test. Readings from the second test are greatly improved. The FP diagnoses the patient with reactive airway disease and probable COPD. 
 
Coding Scenario #1: The correct code is 94060 because the albuterol inhaler is used. The diagnosis code is 493.12 (Intrinsic asthma; with acute exacerbation) because the patient is having an acute exacerbation (shortness of breath). An E/M visit can be coded separately as well, says Pride. Use 99202 (Office or other outpatient visit for the evaluation and management of a new patient ) with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached. A secondary code is not necessary in this case because shortness of breath is intrinsic to asthma and the COPD is not a definitive diagnosis, she adds. 

 
Scenario #2: An asthmatic patient presents with difficulty breathing. The FP administers peak flow to make sure the problem is not serious. The measurement, however, is high, and the physician gives the patient a bronchodilator to open up his airways and takes another peak-flow measurement.
 
Coding Scenario #2: Because the peak-flow measurement is such a quick and simple test, it is not reimbursed, says Ian Easton, PhD, past president of the American College of Medical Practice Executives and current department head of applied technology at Coastal Georgia College in Brunswick, Ga. However, in this case, the peak-flow test included the bronchodilator administration. Code 94060 cannot be used here because a spirometry was not given before and after the bronchodilator; rather, a peak flow was used. Report 94640 (Nonpressurized inhalation treatment for acute airway obstruction) to represent the bronchodilator administration because it is considered a nebulizer treatment in this case.

 
Scenario #3: A patient with allergic asthma presents with wheezing that can be heard on examination. The FP performs pulse oximetry on the patient to measure the oxygen saturation in her blood. The test shows that the patients O2 saturation is 85 percent. Because of the low O2 saturation and wheezing, the FP administers a nebulizer treatment to clear the patients lungs.
 
Coding Scenario #3: For Medicare claims, the pulse oximetry is bundled into the nebulizer treatment and therefore not billable, says Easton. Medicare considers pulse oximetry incidental to any other service performed on the same day. However, if the patient has commercial insurance, you can bill for the pulse oximetry with 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination). Report 94640 for the nebulizer. The diagnosis code should be 493.02 (Extrinsic asthma; with acute exacerbation). Do not code for the wheezing because it is a symptom of the asthma.