Pulmonology Coding Alert

NCCI bundles spirometry with 6-minute walk tests.

When your pulmonologist performs a pulmonary stress test, you'll need to choose between 94620 and 94621, but discerning whether a test is simple or complex to make the right code selection isn't always clear. Our guidelines that follow will help you make this task of reporting a pulmonary stress test easier.

Capture the Stress Test Differences

You will have to know the differences between simple and complex tests so that you will know which of the options to report.

Key: "The first difference is the level of supervision needed. The simple stress requires general while the complex requires direct," says Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Mich.

Your pulmonologist will order a simple test to assess the patient's shortness of breath or wheezing or to assess a patient prior to a lung surgery. "A simple stress test has a baseline spirograph performed, the patient walks on a treadmill until they are short of breath and a repeat spirogram is performed," says Young. When your pulmonologist orders a simple test, you report the test using 94620 (Pulmonary stress testing; simple [e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry]). "The other more common type of simple stress is called a 6 minute walk. For the complex stress, the test records the integration of cardiac and pulmonary function and the status of the patient's physical fitness."

While simple tests can be conducted anywhere, complex testing needs more integrated equipment for the assessment of cardiac and pulmonary function along with measuring parameters such as CO2 production and O2 uptake. So, a complex testing is not conducted in a private office setting and is only conducted in a facility-based setting.

Note: Both the tests need to be supported with documentation that describes the parameters that were measured. "The documentation for a simple test, the 6 minute walk test, is much less complex than for a CPET (cardiopulmonary exercise test)," says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. "For the CPET, you document the O2 uptake, the anaerobic threshold, % of maximum heart rate (HR), blood pressure at rest and exercise, ECG during exercise, O2 pulse, CO2 output, work, VEO2, VECO2, VD/VT, SpO2 plus ratios of these parameters and the time duration of the exercise." When your pulmonologist orders a complex test, you report the test with 94621 (Pulmonary stress testing; complex [including measurements of CO2 production, O2 uptake, and electrocardiographic recordings]).

Interp included: Analysis and interpretations of the test are included in the supporting documentation. "The report of interpretation (whether billing only the professional component or full component) comprises the physician's commentary on the data and what those values mean for this patient," reminds Young.  "The report would also include recommendations for therapy and/or further testing."

Example: Your pulmonologist orders a 6-minute-walk test to assess a patient for shortness of breath (786.05, Shortness of breath). The technician records the patient's heart rate, distance covered, pulse oximetry and degree of dyspnea experienced during the test. The pulmonologist reviews the test results and provides his interpretations in a written report. You report the 6-minute walk test with 94620.

Example2: Your pulmonologist is assessing an established patient with dyspnea that is gradually increasing and affecting his functionality. Since simple testing conducted earlier has been inconclusive towards determining the reason for the dyspnea, your pulmonologist orders a complex test that includes measuring CO2 production, O2 uptake, ventilation and peak cardiovascular response using a graded exercise protocol. Your pulmonologist then analyzes and provides interpretation of these test results in a written report. You report the test with 94621.

Report Professional Component Only for Interpretations

The codes for simple and complex pulmonary stress tests contain professional and technical components. This means that if your pulmonologist provides the service in a facility-based setting, or performs the service in a private office setting but does not own or lease the equipment for the pulmonary stress test, you will have to report the test procedure with interpretations provided by your pulmonologist with the modifier 26 (Professional component) appended to the test code that you are billing. The facility that owns the equipment will bill for the technical component of the procedure using the same CPT® code with the modifier TC (Technical component) appended to it.

Example: Your pulmonologist orders a complex pulmonary stress test in an outpatient hospital department. He provides direct supervision during the test and analyses the test results. He provides his interpretations to the test on a written report. You report the test with 94621-26 and get paid $68.08. The hospital bills the technical component of the procedure with 94621-TC and receives $95.65 in reimbursement.

Observe That Spirometry and 6-Minute Walk Tests are Bundled

The descriptor for 94620 may cause questions about how to report a spirometry with a 6-minute walk test. Your pulmonologist will not always perform a spirometry test with a 6-minute walk test. But when your pulmonologist does perform these tests together, it is vital to know that these two tests run a Correct Coding Initiative (CCI) edit that bundle these two tests with a modifier '1' which mean that these tests cannot be reported together.

However, if your pulmonologist orders these two tests together, you can override the CCI edit by appending the modifier 59 (Distinct procedural service) to the spirometry test.

Example: Your pulmonologist assesses a patient with complaints of wheezing. He performs a spirometry test which doesn't reveal enough information and then decides to order for a 6-minute walk test. He then analyses the test results and provides his interpretations. You report 94620 for the 6-minute walk test and 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for the spirometry with the modifier 59 appended to it.