Pulmonology Coding Alert

Documentation:

Back Up Your Spirometry Claims With Specific Lung Disease Codes

Published on Tue Mar 08, 2022

Hint: Unspecified codes could result in rejections.

Spirometry tests are the most common pulmonary function test (PFT) of pulmonology practices, but physicians need to show the reason why they’re reporting the services, not just that they performed the tests. If the provider’s documentation doesn’t specify a patient’s respiratory disease or complaint, your claim may be held up or rejected.

Read on to understand the importance of assigning specific diagnosis codes on spirometry claims.

What Is Spirometry?

Spirometry measures the amount of air a patient inhales and quickly exhales. Providers use this test to evaluate a patient’s condition and differentiate between obstructive respiratory diseases and restrictive respiratory diseases. Patients with obstructive lung diseases, such as chronic obstructive pulmonary disease (COPD) and asthma, have difficulty exhaling all the air in their lungs. Patients suffering from restrictive lung diseases, like interstitial lung disease and sarcoidosis, are unable to completely fill their lungs with air because their lungs become stiff and cannot fully expand while the patient inhales.

Patients may seek medical attention most commonly when they’re experiencing shortness of breath and exhibiting symptoms of obstructive and restrictive lung diseases, such as:

R05.- (Cough)
R06.2 (Wheezing)
R07.1 (Chest pain on breathing)
R53.83 (Other fatigue)
R09.3 (Abnormal sputum)

If a pulmonologist observes any of these symptoms during a physical examination, they will order PFT to further evaluate the patient’s symptoms and diagnose their condition. However, for a physician to report 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation), documentation must back up the medical necessity for the test.

Show Medical Necessity Using Valid ICD-10-CM Codes

For a provider to receive proper reimbursement for spirometry, there needs to be credible medical necessity for the procedure. How you show medical necessity lies in assigning the correct ICD-10-CM code.

In some cases, physicians use spirometry to confirm a diagnosis or for surveillance in patients with a confirmed lung disease. Your pulmonologist may dictate, document, and communicate patient data incredibly well, but you should take extra care to select the right, most specific code.

For example: If you have a report that indicates a patient underwent a spirometry test and was diagnosed with COPD with a lower respiratory infection, then you’ll need to select the code that reflects the diagnosis. In this case, parent code J44.- (Other chronic obstructive pulmonary disease) carries a 4th character required icon. The 4th character provides greater specificity of the disease. For the example listed here, you should select J44.0 (Chronic obstructive pulmonary disease with (acute) lower respiratory infection). By choosing a specific diagnosis code, rather than an unspecified COPD code like J44.9 (Chronic obstructive pulmonary disease, unspecified), your claim shows a more accurate reason for the spirometry test.

While having a definitive diagnosis after the exam is nice, signs and symptoms show medical necessity in many cases. Often, a physician uses spirometry to investigate a respiratory symptom. If the physician hasn’t made a definitive diagnosis, then you’ll assign codes for the signs and symptoms the patient is presenting. According to ICD-10-CM Official Guidelines, Section I.B.4, you should code the signs and symptoms “when a related definitive diagnosis has not been established (confirmed) by the provider.”

Get Specific Even With Unspecified Codes

Scenario 1: A patient presents to your pulmonology clinic with a cough, an abnormal amount of mucus, shortness of breath, fever, and chills. The physician performs a physical exam and spirometry to evaluate the patient. After reviewing the results of the test and the longstanding history of documented bronchitis, the physician documents unspecified chronic bronchitis.

In this scenario, the documented diagnosis doesn’t show the medical necessity for spirometry. “J42 (Unspecified chronic bronchitis) is not a diagnosis that would support medical necessity according to two of the bigger Medicare Administrative Contractors (MACs) for the Centers for Medicare & Medicaid Services (CMS),” says Julie Davis, CPC, COC, CRC, CPMA, CPCO, CDEO, AAPC-approved instructor, risk adjustment manager for Physician Health Partners in Denver, Colorado. The documentation needs to specify the type of bronchitis, so you can assign the appropriate diagnosis code. Your claim with spirometry reported is more likely to be approved if it includes whether the patient is experiencing obstructive chronic bronchitis (J44.9) or chronic bronchitis due to smoking (J41.0, Simple chronic bronchitis).

In this scenario, the physician provided insufficient documentation. Given the fever and chills that accompanied the shortness of breath and increased sputum production, you should query the physician following your practice’s guidelines for queries. For instance, the physician may clarify that the presentation warrants an “acute on chronic bronchitis” (J20.9, Acute bronchitis, unspecified). This diagnosis better depicts the patient’s complaints and also supports the reason for the testing. Sometimes, queries or feedback during training can assist physicians with understanding how their documentation supports proper coding.

Review Includes Notes to Locate the Correct Diagnosis Code

Scenario 2: An asthma patient presents to your pulmonology practice experiencing shortness of breath, wheezing, chest pain, and coughing. The pulmonologist performs a physical examination and spirometry. The physician documents their findings and reports a diagnosis of asthma with acute exacerbation.

In this scenario, you have sufficient documentation to show the medical necessity for the spirometry procedure. ICD-10-CM code J45.41 (Moderate persistent asthma with (acute) exacerbation) is a complete code that meets the number of characters required for the code category. “We expect the clinician to document [the full diagnosis], so code J45.41 can be used. It wouldn’t be appropriate for the provider to only document asthma, nor would it be appropriate to report J45.909 (Unspecified asthma, uncomplicated),” says JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager of the Children’s Health Network in the Minneapolis/St. Paul, Minnesota area.

Reminder: When patients don’t carry a formal diagnosis of lung disease (such as COPD or asthma), payers may consider certain respiratory symptoms proof of medical necessity for ordering spirometry. Sometimes, the spirometry results aren’t enough for the physician to render a definitive diagnosis, and further testing (such as a chest X-ray) is warranted. However, when patients do have chronic lung disease, it’s important for the physician to identify when there is an acute nature to the illness to distinguish between routine surveillance studies and diagnostic services. This documentation can help support reporting more frequent spirometry services above what’s allowed for routine surveillance.