Pulmonology Coding Alert

Use expert strategies to ensure reimbursement

Although you may have trouble remembering all the pulmonary function test (PFT, 94010-94799) bundles when the pulmonologist diagnoses emphysema (492.0-492.8), don't give up.
 
Our coding experts offer four tips to give your PFT coding skill an update - and to help your physician get the proper payment.

1. Report Signs and Symptoms

A patient with emphysema, a form of chronic obstructive pulmonary disease (COPD, 496), often presents to the office with a variety of symptoms, including shortness of breath (786.05), wheezing (786.07), and breathlessness (786.09).
 
After the patient sees your pulmonologist for symptoms like wheezing and shortness of breath, your physician performs numerous in-office tests to properly diagnose the disease, including PFTs and chest x-rays (71010-71035), says Judy Richardson, RN, MSA, CCS-P, a senior consultant at Hill and Associates, a coding and compliance consulting firm in Wilmington, N.C.
 
You should report codes for the presenting symptoms until your physician diagnoses emphysema. Once your pulmonologist confirms emphysema, however, you can report the appropriate emphysema diagnosis code, such as 492.0, Richardson says. Also, you can list ICD-9 codes, such as 786.07 and 786.09, in addition to 492.0.

2. Know 94010 and 94060 Bundling Rules

When your pulmonologist suspects that a patient has emphysema, make sure you're prepared to code the tests involved. Your physician will perform either a spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) or a bronchospasm evaluation (94060, Bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]). 
 
The bronchospasm evaluation (94060) involves spirometry (94010) taken before and after your physician administers bronchodilation (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered-dose inhaler or intermittent positive pressure breathing (IPPB) device]) to dilate the airways. 
 
Remember that you cannot report both spirometry and bronchospasm tests on the same day - the National Correct Coding Initiative (NCCI) bundles 94010 into 94060. NCCI also bundles several other tests with 94060, including 94375 (Respiratory flow volume loop), 94200 (Maximum breathing capacity, maximal voluntary ventilation), 94770 (Carbon dioxide, expired gas determination by infrared analyzer), 94640 and 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered-dose inhaler or IPPB device).
 
If your pulmonologist performs the test in the office, you may bill for the bronchodilator medication, such as Albuterol (J7618-J7619). But when a physician performs these tests in a hospital or other outpatient facility, you cannot bill for the supplies because the facility delivers them, says Antoinette Revel, CPC, a coding expert and nurse practitioner for Healthcare Consulting Services in Warrington, Pa.

3. Bill 94260 and 94350 Separately

Know which codes you can and can't report when your pulmonologist orders a number of other diagnostic tests and PFTs, coding experts say.
 
The physician can order a chest x-ray (71010, Radiologic examination, chest; single view, frontal) and a diffusing capacity test, such as 94720 (Carbon monoxide diffusing capacity [e.g., single breath, steady state]). Also, your physician may request a lung volume test 94260 (Thoracic gas volume) or 94350 (Determination of maldistribution of inspired gas: multiple breath nitrogen washout curve including alveolar nitrogen or helium equilibration time).
 
Typically, the radiologist will bill for the x-ray, so you should include your physician's review of the x-ray interpretation in the E/M level you use.
 
For instance, instead of reporting low-complexity decision-making for the physician's E/M service, you could document the interpretation and bill for a higher level of decision-making. In addition, NCCI doesn't bundle the above-mentioned PFTs, so you may report them separately.
 
Depending on the emphysema's severity, your pulmonologist may also perform pulse oximetry (94760, Noninvasive ear or pulse oximetry for oxygen saturation; single determination) and blood gas testing (82803-82810).
 
If the physician provides any other billable service (for example, 99203, Office or other outpatient visit for the evaluation and management of a new patient ...), you can't separately report the pulse oximetry. Medicare considers pulse oximetry as incidental and includes the service in other billable services. You should submit 94760 to Medicare only if your physician did not perform any other service on the patient that day, Richardson says.

4. Use Modifier -59 to Separate Bundled PFTs

 When your pulmonologist wants to get paid for both a stress test (94620, Pulmonary stress testing; simple [e.g., prolonged exercise test for bronchospasm with pre- and post-spirometry]) and spirometry (94010), you may face denials because of bundling edits. But you may be able to  combat those denials with modifier -59 (Distinct procedural service), Revel says.
 
For example, your physician sees a 65-year-old woman who has dyspnea (786.09) and cough (786.2) after she walks several city blocks. Her resting spirogram comes back normal, so the physician orders a pulmonary stress test. As she walks on the treadmill, dyspnea occurs, and your physician obtains a repeat spirogram to evaluate the patient for exercise-induced bronchospasm.
 
Even though the original spirometry tested normal, the patient's history showed bronchospasm symptoms, which may establish medical necessity for the stress test and to report the initial spirometry as a separate service, Richardson says.
 
But you should attach a copy of the patient's records to the claim and prepare yourself for an appeal, she adds. 
 
You should link 786.09 (dyspnea) to the initial spirometry code 94010, and 493.81 (Exercise-induced bronchospasm) to 94620 (the stress test). 
 
Try attaching modifier -59 (Distinct procedural service) to 94010, although this does not guarantee payment, particularly for non-Medicare insurers.
 
If your physician does not own the PFT equipment, you should append modifier -26 (Professional component) to 94010 or 94060 for your physician's interpretation of the test results. You can only report these codes without modifier -26 if your pulmonologist both owns the equipment and interprets the results.