Pulmonology Coding Alert

Ignoring CCI bundling in PFT codes may land you in hot water.

If your practice is in the proximity of industrial areas, farmlands, or mines, then you may frequently encounter cases of extrinsic allergic alveolitis (EAA). Although you may think it straightforward to code for EAA, we answer three crucial questions to ensure watertight claims and EAA reporting success.

Background: EAA (also known as hypersensitivity pneumonitis) is an inflammation of the lungs caused due to repeated breathing of foreign substances, usually of organic origin (such as certain types of dust, fungus, or molds) by susceptible subjects. The condition, which is usually occupational, can lead to lung inflammation and acute lung disease upon long-term exposure. EAA induces a hypersensitivity response in the distal bronchioles and alveoli and subjects may present clinically with a variety of symptoms.

#1: Can You Report All Tests For Your Physician?

For example, a patient presents to your pulmonologist with fever, aches, dry cough, and shortness of breath. To eliminate other conditions and confirm a diagnosis of EAA (495.x), your pulmonologist will take many steps to diagnose this condition properly. Just diagnosing it outright as EAA may be a dangerous conclusion.

The physician may recommend several pulmonary function tests (PFT), blood work, x-rays, etc. including:

• 31624 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage)
• 71015-71555 (Diagnostic Radiology [Diagnostic Imaging] Procedures of the Chest) for the chest x-rays
• 85025 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count)
• 86001 (Allergen specific IgG quantitative or semiquantitative, each allergen)
• 94070 (Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents [e.g., antigen[s], cold air, methacholine]) for postexposure evaluation;

The physician will also order tests such as 94375 (Respiratory flow volume loop), 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) for lung volume and 94729 (Diffusing capacity [eg, carbon monoxide, membrane] [List separately in addition to code for primary procedure]) for diffusing capacity. You may also find 95071 (Inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with antigens or gases, specify) for antigen challenge testing in the list.

Caution: “Tread very carefully when reporting these tests for your facility/office. The rule of thumb: If you are in a private office setting (POS 11) and you own it, you claim it. That generally means that you can safely report the PFTs if your physician owns the equipment,” warns Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.

For example, you should not claim prolonged postexposure evaluation (94070) and antigen challenge test (95071) on behalf of your physician if the PFTs were not conducted in the physician’s privately-owned PFT lab. If a hospital-based PFT lab performed the PFTs, then you will report only the professional components of the service by appending modifier 26 and the lab will report the technical components. So, in the case of bronchospasm evaluation, you will report 94070-26 and the test facility will claim 94070-TC. Similarly, double check when billing for the laboratory tests (85025, 86001, etc.) as you can claim for these services only if your office is certified to process and analyze the specimens.

#2: Are You Missing Out on E/M Reimbursement?

Although the tests are the conclusive method of diagnosing the exact hypersensitivity pneumonitis allergen, your pulmonologist is in still in the best position to initially find the best evidence for this condition. She will do this by taking the patient’s history, by finding the patient’s occupation, and a history of exposure to animal or vegetable dusts.

Therefore, it is very possible that your physician spent a considerable time in attending to the patient and performing some level of medical decision making (MDM). In your hurry to report the tests conducted on the patient, are you neglecting to claim the E/M encounter between the physician and the patient? You may be missing out on well deserved E/M payment. Check the physician’s notes to verify that she performed this service, and then bill the appropriate level of E/M care. Depending on the qualifying conditions, you may report the office visit code from among:

• 99201-99205 (New Patient Office or Other Outpatient Services)
• 99212-99215(Established Patient Office or Other Outpatient Services).

#3: Are You Violating Any Correct Coding Initiative (CCI) Bundles?

After doing all due diligence on your office visit and tests coding, you may still find your claims rebounding if you have not sifted carefully through the convoluted maze of CCI bundles and exclusions. For example, if the pulmonologist ordered both Plethysmography (94726) and gas dilution (94727) as diagnostic tests, you can report only one of them according to CCI edits.

Why: “CPT® 94727 is a column 2 code for 94726, which means you cannot bill these codes together unless there are extenuating circumstances. If you can obtain the necessary clinical information from one set of testing, then the payer may not perceive the second set of testing as being medically necessary. You should confirm the local coverage determination (LCD) rules with your insurance carriers first about their policy,” informs Pohlig.

Similarly, 94375 is a component of the antigen challenge test 94070. While you should not report them together on the same day, the CCI edits allows a modifier to differentiate between the services provided for separate reasons during separate sessions on the same day.

Another code that bundles into 94070 is 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). The only time you would report these codes separately is when the pulmonologist orders spirometry for a separate and distinct reason. For example, prolonged post-exposure evaluation (94070) can only be reported if the physician notes that 94010 results indicated a problem that required additional testing. Remember to attach modifier 59 (Distinct procedural service) to 94010 to show that this code is distinct from 94070 if both were ordered together.

Similarly, you cannot bill pulse oximetry (94760, Noninvasive ear or pulse oximetry for oxygen saturation; single determination) on the same day as any other billable service because the 94760 “T-status” bundles the corresponding payment into all other same-day payments.