Pulmonology Coding Alert

Confirm medical necessity to avoid the spirometry denials trap

When your pulmonology practice performs exercise tests or bronchodilator studies, do you need to append a modifier to unbundle the services? If you do, you may face a denial. Ask yourself these two questions to make sure you're reporting your spirometry services correctly. 1. Are you thinking about unbundling for a patient with normal spirogram results? Suppose your physician sees a patient who complains of hyperventilation (786.01) and coughing (786.2).
The patient's resting spirogram comes back normal, so the physician orders a pulmonary stress test. As the patient walks on the treadmill she hyperventilates, and the physician performs a repeat spirogram to evaluate the patient for exercise-induced bronchospasm.

Generally, because most carriers consider spirometry to be a part of the pulmonary stress test, you might think you can't report the initial spirometry as a separate service. But think again. 

You may report spirometry, but only if it occurred at a separate session. If the physician initially orders the spirometry to diagnose the patient's presenting problem, as above, you should not consider the spirogram to be part of the pulmonary stress test because the results of spirometry prompted the physician to order the pulmonary stress test. If you have appropriate documentation to support the separate nature of these services, you may report 94010-59 (Spirometry ...; Distinct procedural service) in addition to the stress test. 

Exception: Remember that spirometry is a pulmonary function lab test, so you should never bundle it into your E/M, says Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy and critical care at the Emory University School of Medicine in Atlanta.

If the physician also provided an E/M service, you should report only 94620 (Pulmonary stress testing; simple [e.g., prolonged exercise test for bronchospasm with pre- and post-spirometry]), Plummer says.

Advice: Make sure you link ICD-9 code 493.81 (Exercise-induced bronchospasm) to 94620, he says. Also remember to link 786.01 and 786.2 to your E/M code (99201-99215 for outpatient spirometry. 2. Did the physician perform spirometry and bronchospasm evaluation on the same day?
 
If your physician suspects that a patient has emphysema, he will likely order a bronchospasm evaluation (94060,  Bronchospasm evaluation: spirometry, as in 94010, before and after bronchodilator [aerosol or parenteral]). During this procedure, the patient undergoes spirometry (94010) before and after a bronchodilation to dilate his airways, Plummer says.

You can't charge separately for the cost of the bronchodilator with medication that the patient received because the practice expense relative value [...]