Primary Care Coding Alert

Many family practice coders describe significant confusion regarding how to properly report pulmonary function tests (PFT) performed in their physicians offices. At first glance, there are an overwhelming number of codes listed in the pulmonary portion of CPTs Medicine section. However, only a couple of these codes typically are used by a family physician.

Most family physicians will perform spirometry as described in codes 94010 and 94060, explains Cynthia DeVries, RN, CPC, coding and reimbursement specialist with Lee Physicians, a 140-physician practice in Fort Myers, Fla. CPT defines these two codes as:

94010 spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation; and

94060 branchospasm evaluation; spirometry as in 94010, before and after bronchodilator (aerosol or parenteral).

There are a variety of additional codes, but many are considered bundled into 94060 by the Correct Coding Initiative (CCI) including 94200 (maximum breathing capacity, maximal voluntary ventilation), 94375 (respiratory flow volume loop), 94640 (nonpressurized inhalation treatment for acute airway obstruction), 94650 (intermittent positive pressure breathing [IPPB] treatment, air or oxygen, with or without nebulized medication; initial demonstration and/or evaluation), and 94770 (carbon dioxide, expired gas determination by infrared analyzer). These component codes cannot be reported on the same date in addition to 94060.

Spirometry is a basic ventilation test within the battery of assessments included in pulmonary function testing, according to Cynthia Thompson, CPC, senior consultant at Gates, Moore & Co., a physician practice management and consulting firm in Atlanta. A family physician will most often use spirometry for preoperative testing, to evaluate lung disease, to appraise the effect another systemic disease has on pulmonary functions or to assess the effectiveness of a treatment, she says. During the study, a spirometer is used to measure tidal volume, inspiratory reserve volume, expiratory reserve volume, residual volume, inspiratory capacity and vital capacity.

Each measure is generally taken three times and an average result is calculated, Thompson explains. However, coders may bill only one unit of service for these measurements that are part of spirometry.

A bronchospasm evaluation differs in that spirometry is performed before and after a bronchodilator (a drug that relaxes the bronchial muscles) has been administered to the patient. While the same machine is used, the entire series of tests is often not needed. The test most often used is a peak flow, or an evaluation of how fast the patient can move air in and out of his or her lungs. Coders should note that when a bronchospasm evaluation is conducted, you would report only 94060, Thompson explains. Code 94010, describing spirometry services, is considered bundled into 94060 by both Medicare and CPT.

Some practices may not own a spirometer and may instead use a simple peak flow meter. A peak flow meter measures only the flow of air and not lung capacity. Because a true spirometer is not used in these instances, some carriers may not allow code 94060 to be reported even though the peak flow meter performs a similar function and measures the activity of the bronchodilator. Family practice coders should check with their local medical review policy (LMRP).

Whether a family practice bills for the bronchodilator used during the bronchospasm evaluation depends on the payer involved, DeVries adds. Because the CPT definition mentions the use of the drug, many payers regard it as a standard component of the procedure. However, the CCI doesnt include the J codes used to report drugs in its edits, so its difficult to determine whether Medicare considers the drugs bundled into the procedure.

Coders should contact local carriers and private payers to determine their policies about billing bronchodilators.

Code Should Reflect Symptoms, Not Risk Factors

When reporting PFT services, family practice coders must follow closely local carrier policies regarding diagnosis coding. One of the most important issues to remember, says DeVries, is to assign ICD-9 codes that describe specific signs and symptoms. Most payers wont accept risk factors like family history of asthma (V17.5) or family history of other chronic respiratory conditions (V17.6).

A survey of several LMRPs indicates that many carriers have policies similar to Nationwide Medicare, the Part B administrator for Ohio and West Virginia. Nationwide policy notes, Regardless of the number of risk factors which a patient has, spirometry is not covered in the absence of symptoms. Palmetto G.B.A., the local Medicare carrier in South Carolina, has a similar policy and adds, PFTs are not covered when performed as screening tests without relationship to specific signs or symptoms of illness or injury.

Among the signs and symptoms accepted by most carriers are chronic cough, dyspnea, wheezing, orthopnea, over-inflation of lungs, cyanosis, hypoxemia, polycythemia and abnormal chest x-ray. Diagnosis codes that are commonly covered include:

466.0-466.1 acute bronchitis and bronchiolitis
491.0-491.21 chronic bronchitis
492.0-492.8 emphysema
493.00-493.91 asthma
782.5 cyanosis

However, family practice coders whose physicians regularly perform spirometry should check policies published by Medicare and private payers for a list of covered ICD-9 codes because they can vary significantly from payer to payer. Nationwide Medicare and Palmetto, for example, instruct family physicians to use V72.82 (preoperative respiratory examination) when spirometry is performed as part of a preoperative test and to list the surgical condition as the second diagnosis. In New York, however, Empire Medicare Services states that it will not cover that same preoperative testing code for spirometry. Georgias Cahaba Government Benefits Administrator specifically excludes the commonly used 491.0 (simple chronic bronchitis) and 491.1 (mucopurulent chronic bronchitis) from its list of covered diagnoses.

Limits Placed on Bronchospasm Evaluations

In addition to covered and noncovered ICD-9 codes, medical policies may also stipulate a number of coverage issues that must be met to prove the medical necessity of the PFT. Many local Medicare carriers have a policy similar to Floridas First Coast Service Options that limits the use of bronchospasm evaluations. Once it has been determined that a patient is sensitive to bronchodilators, the policy reads Repeat bronchospasm evaluation is usually not medically necessary. The Florida carriers policy goes on to restrict the use of the bronchospasm evaluation after a patient has had normal results from a spirometry.

Local carriers may also place restrictions on when spirometry can be repeated. Nationwide states in its policy that, Repeat spirometry performed for patients on bronchodilator therapy presenting without new symptomatology is considered routine screening and therefore not covered. The policy goes on to state, PFTs are covered for initial workup for a patient with a chronic cough. It is not expected that a repeat spirometry will be performed without additional symptomatology or failure to respond to a prescribed treatment.

Bill Office Visits Separately When Appropriate

Family physicians may be able to report an office visit in addition to the PFT. CPT states, If a separate identifiable evaluation and management service is performed, the appropriate evaluation and management (E/M) service code should be reported in addition to 94010-94799.

The office visit, however, must be a full-service visit to be separately billable, DeVries emphasizes. The physician can count the results of the PFT as medical decision-making, but there also must be some history taken and a further assessment of the lungs done before the visit will qualify as a separately billable service, she explains. If the patient comes into the office just to take the test, you should not report an additional E/M service.

Some payers may require the use of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) with the E/M service. Family practice coders should contact their payers to get specific coding instructions.