Pulmonology Coding Alert

Halt pulmonary function test denials by ensuring correct modifier use.

If pulmonary function tests are daily services for your practice, you may think you have the coding rules committed to memory. But the truth is many coders still have questions about reporting these common procedures. Avoid denials by reviewing these spirometry ins and outs.

Use Two Codes for New Patient Testing

Nearly all new patients with respiratory symptoms are subject to a baseline spirometry (94010,  Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). When the pulmonary function technologist performs this test, normal procedure is to print the graph of the spirometric tracing, print the values for vital capacity, forced vital capacity, and flows, and put that information in the chart after the pulmonologist interprets the results.

At the first visit, the practice reports spirometry along with the appropriate E/M code for a new patient (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) or consult (99241-99245, Office consultation for a new or established patient ...), when applicable. Because the Correct Coding Initiative (CCI) bundles the E/M codes into 94010, you'll need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of theprocedure or other service) to the E/M code so the payer doesn't deny the E/M payment.

Going forward, established patients are tested with spirometry whenever their symptoms or complaints warrant it and the pulmonologist feels it is necessary, or after treatment initiation to determine improvement and appropriateness of therapy.

Confirm POS Is Accurate

When deciding whether to break out 94010's professional and technical components, the service's setting can typically offer clues. If your office is in a private office setting (place of service 11) and the practice owns the machine, employs the technician, and the physician does the interpretation, you'll report 94010 without any modifiers.

Don't miss:  In facility-based locations (for instance, place of service 22), switch from the global code to a modifier-appended code. For example, if your pulmonologist interprets spirometries that patients receive at a local hospital, the hospital bears the cost of the equipment and physical space. Therefore, you would append modifier 26 (Professional component) to the appropriate pulmonary function test code, and the hospital would append modifier TC (Technical component) to the same codes and submit a separate bill.

Support 94618, 94060-59 With 3 Differences

The CCI bundles 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) into the six-minute walk test (94618, Pulmonary stress testing [eg, 6-minute walk test], including measurement of heart rate, oximetry, and oxygen titration, when performed). You can use modifier 59 (Distinct procedural service) or the appropriate X modifier (eg, XU, Unusual Non-Overlapping Service) if recognized by the payer, however, to break this bundle if the pulmonologist performs and clearly documents a medically necessary separately identifiable service.

Support the spirometry as separate with these facts:

1. Separate measurements: These two tests-- 94060 and 94618-- essentially measure completely different things, which can help you separately identify them. Bronchodilation responsiveness includes spirometry, which measures the patient's vital capacity and pulmonary flows (FEV1, FEF 25 percent-75 percent, etc.) before and after bronchodilator administration. The six-minute walk measures how a patient fares during exercise and the distance he is able to achieve.

A physician commonly orders a six-minute walk to decide whether to prescribe oxygen. Conditions that may require this type of test include chronic obstructive pulmonary disease (J44.1), emphysema (J43.9), or pulmonary hypertension (I27.0).

2. Different reasons: A patient may require the two tests for separate reasons in order to determine diagnosis, monitoring, and treatment options. For instance, if the pulmonologist performs a PFT to monitor how the patient's disease is progressing-- for example, decreasing lung volume-- she may additionally order a six-minute walk to evaluate whether the patient can walk farther on the current treatment regimen. In this case, you would append 59 to the bundled service: 94060.

3. Involved Areas: You can also differentiate spirometry and the six-minute walk by looking at studied anatomy. A PFT involving spirometry measures lung volume (vital capacity and/or forced vital capacity) and flow. A physician uses 94618 to determine the patient's exercise capabilities, which involve the lungs, heart, muscles, and circulation. Also, 94618 does not include a bronchodilator response, which is a feature of 94060.

Example: A patient performs a six-minute walk (94618) and the pulmonologist determines that her responses suggest a more involved lung condition. She then decides to order a bronchodilation responsiveness study to see if the patient's respiratory status improves after bronchodilation. In this case, you would also append 59 to 94060.

Include Pulse Ox in E/M

You cannot, however, unbundle one particular service you typically also provide with spirometry. While every patient may also receive pulse oximetry readings (94761, Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations [e.g., during exercise]), pulse oximetry is not separately payable as it is bundled into any other payable service performed on the same day by the same provider/specialty group. Although you should document the oximetry readings, in most cases you will not separately bill for them.