Pulmonology Coding Alert

Appropriate documentation and modifier usage does the trick.

When your pulmonologist performs a methacholine provocation challenge test to evaluate the responsiveness of a patient's airways, he may use spirometry following the testing to see if there is a bronchospastic response. To report these services accurately, you'll need to know how to report the tests, spirometry and any other E/M services provided during the encounter. Read on to get better grasp on the guidelines that will help you beat methacholine challenge test reporting when your pulmonologist performs them.

Know When to Report Professional and Technical Components Separately

When reporting methacholine provocation testing, you first need to report the administration of the methacholine with 95070 (Inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds). The methacholine provocation test should be reported using 94070 (Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents [e.g., antigen[s], cold air, methacholine]).

Key factors: To arrive at the right testing code, you'll need to know "testing location, component services, coding edits, and additional visits," advises Mary I Falbo, MBA, CPC, President of Millennium Healthcare Consulting, Inc., Lansdale, PA. "Code 94070 can be divided into a technical and professional component. For example, if the physician supervises and interprets the test in a hospital-based pulmonary function testing lab (PFT), he or she bills the professional component or interpretation with 94070 and appends modifier 26 (Professional component)."

"The professional interpretation and report (94070-26) may be provided by the physician apart from testing, and then the lab or hospital bills the technical component by appending modifier TC (Technical component) to 94070 if the lab administered the test," says Falbo. "If the professional and technical components were performed in the physician's office, both can be billed by the physician reporting a single unit of 94070 with no modifier."

Caution: "Code 95070 cannot be divided into technical and professional components," adds Falbo. "Whoever administers the drug, bills for it. If the administration occurs in a hospital setting, the hospital bills for the administration of the methacholine (95070). If the administration is performed in the physician's outpatient office or lab, then the physician bills for it."

Also, don't forget to report the methacholine use. Report this with "J7674 for each mg of methacholine," says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. "If 10 mg of methacholine were used, then one would code J7674x10."

Capture These Vital Details From the Documentation

When your pulmonologist administers a methacholine challenge test, your report is incomplete if certain key details are missing. "Physician documentation must include the indication for testing, the method utilized, obtained data, evidence of physician supervision, as well as physician interpretation and report," says Falbo. "Failure to document any of these elements precludes claim submission, or prompts refunds for claims paid inappropriately as a result of incomplete documentation," she adds.

For example: For the test, the patient was administered increasing concentrations of methacholine to inhale and your pulmonologist performs spirometry after the administration of each dose to see if bronchoconstriction has occurred. If you see a significant drop in FEV1 (Forced expiratory volume in 1 second), generally 20 percent, from baseline, you can consider this to be a positive response. You may also see the patient experiencing some symptoms such as cough, wheezing, tightness or dyspnea. Your pulmonologist will cease testing when the patient shows this significant fall in FEV1. If the patient does not show any changes in FEV1 even when a maximal dose is inhaled, the test would then be considered negative.

Documentation tip: The report should show values of FEV1 and FVC (Forced vital capacity) at baseline, following the administration of nebulized saline (diluent) and then following the administration of increasing doses of methacholine.

Observe When to Report Spirometry Separately

Your pulmonologist will perform a baseline spirometric reading, once methacholine has been administered. You cannot report this or any other subsequent spirometries with 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) as spirometric readings associated with methacholine testing are included in 94070.

"An initial spirometry could be reported separately with a 59 modifier (Distinct procedural service), 94010-59, but only if that test were used to make the decision to perform the methacholine challenge," says Plummer.

Here is an example shared by Plummer:

"An established patient with a persistent cough is seen in the office for a level 4 exam. Screening spirometry revealed normal values. A decision was made to schedule a methacholine challenge which was performed later that same day.

You would code 99214 (Office or other outpatient visit for the evaluation and management of an established patient which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family), 94010-59, 95070, 94070, J7674x10." In this scenario, since the spirometry was done prior to the methacholine challenge test, you can report it by adding the modifier.

Understand Guidelines for Reporting an E/M Visit Separately

Methacholine challenge test may include other services, so you'll need to know when you can also report an E/M code separately for the visit. "Physicians need to keep in mind the difference between pretest evaluation and a separate/distinct E/M," says Falbo. "This guides physician selection of the appropriate testing method and identifies any contraindications related to the patient's current health status, recent conditions, exposures, or medications that can alter airway responsiveness, causing a false-positive or false-negative response."

"The pretest evaluation is not reported separately from the test since it is an integral part of the testing process," says Falbo. "If a separate evaluation and management (E/M) service (i.e., visit) occurs, for example, to address separate clinical conditions or address other management options, the physician submits a claim for the E/M along with the appropriate procedure code," she says.

Modifier 25 tip: "Append modifier 25 (Separately identifiable evaluation and management service performed on the same day as a procedure or other service) to the E/M (e.g., 99214-25) to alert the payer that the E/M exceeds the typical evaluation associated with testing, warranting additional payment," points Falbo. "Please note that modifier 25 merely proposes additional payment but does not guarantee it."