Pulmonology Coding Alert

Although carriers regularly reject pulmonary function test (PFT) claims based on medical-necessity problems and Correct Coding Initiative (CCI) bundles, using CMS and local medical review policies (LMRP) guidance will help you ensure proper payment. Pulmonologists use PFTs as the main tool to diagnose pulmonary conditions. The Johns Hopkins Bloomberg School of Public Health made this readily apparent when it reported that World Trade Center cleanup workers are suffering from acute respiratory symptoms. "Many of the workers we assessed reported coughing, wheezing and sore throats while working at Ground Zero," says Alison S. Geyh, PhD, chief investigator and assistant professor of environment health sciences at the school. Particularly, investigators used spirometry (94010, 94060) to measure lung function. Spirometry Codes and Indications Pulmonary function testing provides information regarding the physiology of ventilation, mechanical abnormalities in respiration and gas diffusion elements for patients with breathing difficulties or other specified conditions. Generally, simple spirometry which measures the volume and flow rate of expired air sufficiently differentiates obstructive and restrictive disorders and determines their severity.

Code 94010 describes the basic test, whereas 94060 describes the test performed before and after the pulmonologist administers a bronchodilator. Codes 94014-94016 refer to the patient-initiated spirometric recording per 30-day period, which the physician uses to diagnose and monitor the patient's progress with upper and lower respiratory disease and related problems.

The pulmonologist may use 94070 after the results of 94010 indicate reduced airflow. Code 94375 represents a procedure that allows the physician to determine the amount of air remaining in the lungs after the patient exhales. Medicare carrier LMRPs nationwide specify minimum indications to establish medical necessity for using PFT codes, which may include any of the following:

to identify the cause of a significant symptom such as cough
to assess breathing in a patient who has a condition that may affect breathing such as muscular dystrophy
to guide the initiation of therapy
to assess the effect of therapy
to assess breathing capacity preoperatively
to monitor a patient who is taking a drug that may cause respiratory side effects. To further establish medical necessity, you must include an approved diagnosis with claims (for more about diagnosis coding for spirometry, see the August 2002 Pulmonology Coding Alert article "Easy Tips to Take the Pressure Off Diagnosis Coding for Spirometry"). Payers generally accept a wide range of ICD-9 codes for these tests, but using a covered diagnosis does not guarantee reimbursement. The clinical record must justify the diagnosis and the frequency of testing. For example, Medicare will not reimburse for spirometry to screen a "healthy" patient for possible breathing problems. Report diagnoses to the highest possible level of specificity, i.e., when a five-digit code [...]