Last year, Medicare split code 94620 (pulmonary stress testing, simple and complex) into two codes. They are: 94620 (pulmonary stress testing; simple (e.g., pro-longed exercise test for bronchospasm with pre- and post-spirometry) and 94621 (... complex [including measure-ments of CO2 production, O2 uptake, and electrocardiographic recordings]). This decision recognized the difference in the resources required by these two stress tests. Walter J. O'Donohue, Jr. MD, FCCP, FACP, a representative to the AMA CPT Advisory Committee for the American College of Chest Physicians (ACCP) and CRT/RUC Committee Chairman of the ACCP, points out that these differences are so vast that one code cannot accurately reflect two such disparate tests. This change has been welcomed by most pulmonologists because it has allowed their practices to realize reimbursement previously lost.
According to Cynthia Somma, CPC, a coder for the Nassau Queens Pulmonary Associates, a four-physician practice in New Hyde Park, N.Y, "When the two tests were embodied into one code, most practices couldn't meet the requirements to realize reimbursement for their services." She goes on to explain that most pulmonologists perform only the simple test because the complex one is more suited to a hospital or specialized setting due to the time, equipment and level of physician supervision. The requirements, however, of the original code included the more complicated and detailed service for the complex test. As a result, most practices could not meet them and also lost compensation for performing the simple test.
Requirements for Simple Stress Tests
Even though this change in coding has been a marked improvement, coders still need to be aware of the requirements for the procedure and involvement of the pulmonologist for each test to obtain maximum reimbursement.
The simple pulmonary stress test is usually performed on patients who fall into one of the following categories:
those with the physical conditions of unexplained shortness of breath, pulmonary hypertension or pulmonary fibrosis;
those undergoing pre-op evaluation for a lung transplant or major lung surgery;
those undergoing disability evaluation to determine the severity of a disease such as brown lung disease; or
those undergoing evaluation to determine if they meet Medicare's requirement for supplemental oxygen.
Usually, this test is performed to determine the severity, not the cause, of the patient's condition. One procedure involves measuring lung volumes and flow rates before and after exercise to document bronchospasm.
It requires the general supervision of the pulmonologist as defined by Medicare's revised definitions of physician supervision of diagnostic tests which went into effect in July 2001, meaning that this diagnostic procedure is performed under the physician's overall direction, but his presence is not required during the actual performance of the test, although he should be available by phone or beeper. The physician, however, is responsible for training the nonphysician professional who conducts the test as well as for the continued maintenance of the equipment and supplies needed. (Note: See the June, 2001 Pulmonology Coding Alert for more details on the changed physician supervision levels).
The following two examples would be coded using 94620:
A 65-year-old woman is seen by her pulmonologist for shortness of breath and a cough. Her physical examination and spirogram are normal. A simple stress test is performed. The woman walks on a treadmill until she becomes short of breath and a second spirogram is obtained to evaluate for exercise-induced bronchospasm.
Note: As the example below shows, a treadmill does not necessarily have to be used.
A 65-year-old woman with documented COPD is undergoing evaluation for entrance into a pulmonary rehabilitation program. A simple stress test is performed, with the woman walking for six minutes so that distance walked, dyspnea, desaturation and heart rate can all be evaluated. After a brief rest period, the patient repeats the test. Even though the test is repeated, it is coded only once because the first time is considered a learning experience.
O'Donohue cautions that in order to get reimbursed from Medicare for the simple stress test, more than just oxygen saturation has to be measured; heart rate, distance walked and shortness of breath must also be included. The reason for this, as he explains, is related to Medicare's current refusal to reimburse claims submitted for code 94761 (noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations [e.g., during exercise]). "If a practice does not document that more than just oxygen saturation was measured, then Medicare assumes that an oximetry, not a simple stress test, was performed and rejects the claim" says O'Donohue. To prevent this from occurring, the physician must write a report, documenting the results.
Requirements for Complex Stress Tests
A complex stress test is usually indicated by more complex symptoms. It involves the integration of both cardiac and pulmonary functions with the status of the patient's physical fitness and is usually used when looking for the underlying cause, either cardiac or pulmonary, for a patient's symptoms. Accordingly, the exercise equipment needed is more involved than the treadmill used for the simple stress test. In addition, the measurements recorded are more extensive and complicated than the lung volumes and flow rates measured in the simple test. For the complex stress test, carbon dioxide production, oxygen uptake and electrocardiographic recordings of the patient's response to stress are measured in addition to data about peak cardiovascular and ventilatory responses being recorded. These are complex metabolic tests, and the pulmonologist must analyze, evaluate and interpret the results. Using these results, he or she is able to formulate such calculations as a dyspnea index, an anaerobic threshold as a percentage of maximum oxygen uptake and consumption as it relates to cardiac uptake. As a last step, the physician prepares a written report interpreting the test results.
The level of physician involvement is more intense for the complex stress test than for the simple one. Thus, this diagnostic test must be performed under the direct supervision of the pulmonologist, meaning that he or she must be present in the office area and be immediately available to offer guidance and direction if either is needed during the performance of the test. Even though the doctor's presence is not required in the room during the test according to Medicare guidelines, O'Donohue indicates that the pulmonologist is usually present the entire time required to monitor it, a further indication of the level of professional involvement required by this procedure.
The following is an example of a situation that would be coded using 94621:
A 66-year-old male complains of unexplained shortness of breath, which interferes with his ability to work and exercise. A complex stress test is administered after other attempts to identify the cause fail. Under the stress of exercising, his carbon dioxide production, oxygen uptake and electrocardiographic readings are monitored, and his peak cardiovascular and ventilatory responses recorded. After analyzing and evaluating the results, the pulmonologist writes a report containing the interpretation.
Requirements for Both Tests
There are three other considerations to ensure prompt and complete reimbursement from Medicare when submitting claims for both types of tests:
1. Depending on the office equipment and staff, you may have to separate a portion of the global code by using modifiers -TC (technical component) or -26 (professional component).
2. Appropriate documentation needs to be supplied for each test. This is especially important for the simple stress test in light of Medicare's assumption that without documentation an oximetry, not a simple stress test, has been performed. To prevent this assumption, a report not only documenting the measurement of distance, heart rate and dyspnea in addition to oxygen saturation, but also the physician's interpretation of these results, is needed.
3. Since the simple stress test requires general supervision of the pulmonologist, the files of the employees administering the procedure should contain notification indicating that they have successfully completed the necessary training, and the printout from the procedure should be placed in the patient's chart. For complex stress testing, which requires the direct supervision of the physician, the written report interpreting the study supplies the documentation.
