Pulmonology Coding Alert

There are two different codes 94070 and 95070 for methacholine challenge tests, (MCT) and coders may have difficulty choosing when to use one over the other.

Code 94070 (prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics) should be reported when the actual test is performed using methacholine, provocholine or other means to induce bronchospasm, according to Walter J. ODonohue, MD, chairperson of the CPT committee of the American College of Chest Physicians (ACCP) and a representative to the AMA CPT advisory committee for ACCP.

If it is administered in a hospital laboratory, the physician must report 94070-26 (professional component) to indicate that he or she only interpreted the results. This is because the pulmonologist does not own the testing site. However, if it is given in the doctors office, the code is reported without a modifier. In addition, the physician may use 95070 (inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds) for the administration of the methacholine or provocholine.

Note: If the test is performed at a facility other than the physicians office, only the facility can report 95070.

Coding Methacholine Tests With Spirometry

Generally, you cannot code for both a spirometry (94010, spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) and 94070 performed on the same date, even if the two procedures are done for separate and distinct reasons, explains Carol Pohlig, CPC, RN, a reimbursement analyst for the office of clinical documentation in the department of medicine at the University of Pennsylvania in Philadelphia.

CCI guidelines issued by HCFA state that spirometry is included in the codes for MCTs, says John S. Burns, CPC, RMC, a coder with the Medical Management Institute, a medical practice consulting firm in Alpharetta, Ga. It is always bundled into 94070 and should never be coded separately. He notes that an exception is if the spirometry is done on a different day.

This may be confusing because CPT Assistant (Jan. 1999, page 8) has stated that 94010 may be reimbursed separately when reported with 94070 for the same date of service if spirometry was initially performed to determine if methacholine testing was necessary. But in 2000, HCFA incorporated the code pair in the CCI edits with a 0 superscript. This superscript indicates that modifier -59 (distinct procedural service) cannot be placed on the code to override the edit and unbundle the two procedures for separate payment. Because HCFAs CCI edits take precedence, you should consider 94010 to be bundled with 94070.

Alternately, you can code 94010 and 95070 together, but only if separate and distinct reasons are presented for performing the spirometry, Pohlig explains. But if 94070 appears on the claim form for the same date of service, Medicare will likely deny reimbursement for 94010, she cautions.

The modifier -59 should be used to indicate this distinction between the two, Burns says. It is also recommended to list separate diagnosis codes, which will add to the credibility.

Note: Even if the carrier pays the claim with the same diagnosis code listed for the two services, it will be questioned upon audit.

When Are These Tests Medically Necessary?

Patients with normal pulmonary function at rest usually present with cough, dyspnea, wheezing or chest lightness. They have not responded to therapeutic trials of bronchodilators. MCTs may be used to monitor environmental control of bronchospastic-inciting agents or response to therapy in suspected asthma cases.

They are diagnostic sensitive, explains Debra Anderson, a 13-year coding consultant with Salem Pulmonary Associates in Salem, Ore. For example, if she codes an MCT with 516.3 (interstitial lung disease), carriers want to see chart notes from the procedure. But if she codes the procedure with 786.09 (dyspnea, other), they accept it.

This is because MCTs are usually considered medically necessary when the following ICD-9 codes are used:

493.00, 493.10, 493.20, 493.90 asthma suspected

786.00-786.09 respiratory abnormality such as dyspnea, tachypnea, hyperventilation, wheezing and shortness of breath unrelieved by bronchodilator

786.2 cough


Professional and Technical Components

Although 94070 need not be performed by a physician and can be administered by one of the pulmonologists qualified staff, the physician must interpret the results. If the staff member is not employed by the doctor, the physician can report only his or her portion of the service with 94070-26, using modifier -26 (professional component) to indicate that part of the procedure. The facility, which typically employs the staff where the test is performed, will report the technical component with 94070-TC. Multiple spirometric determinations cannot be billed because they will be considered bundled with 94070, Anderson says. Also, more often than not, private carriers in addition to Medicare will bundle a simple spirometry, such as a flow loop volume, with 94070.