Pulmonology Coding Alert

Pulmonologists treating patients for asthma may assign codes from several sections of CPT depending on the specific diagnostic and therapeutic services provided. To optimize reimbursement, professionals must understand coding conventions governing relevant procedure codes, as well as the intricacies of reporting the medical necessity of the E/M services.
Establishing the Initial Diagnosis
According to Donald Aaronson, MD, a specialist in asthma and allergies practicing in Chicago, physicians perform a variety of pulmonary function tests (PFTs) to establish a diagnosis of asthma. "Typically, a patient presents with symptoms like chronic cough (786.2), wheezing (786.07) or shortness of breath (786.05). The pulmonologist administers appropriate PFTs to determine the cause of the condition."
 
In most cases, he says, the pulmonologist conducts a baseline evaluation using spirometry. If the results indicate asthma, the physician administers a bronchodilator to relax the bronchial tubes and retests the patient's pulmonary function to determine if the medication improves breathing. This three-step procedure is reported with 94060 (bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]).
 
The reference to 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) within the code description indicates that baseline spirometry before bronchodilation is included in 94060. Both Medicare and CPT consider 94010 bundled into 94060.
 
In some cases, results from the baseline spirometry are normal, and, Aaronson says, the pulmonologist may conduct a methacholine challenge test to pinpoint the diagnosis for the patient's breathing disorder. The administration of this test is described with 95070 (inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds]). And, you should report 94070 (prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics) to describe the PFT that measures the impact of the methacholine.
 
Under these circumstances, it is appropriate to report the initial spirometry (94010) appended with modifier -59 (distinct procedural service). This has been a point of confusion when submitting Medicare claims because the national Correct Coding Initiative (CCI) bundles 94010 into 94070. However, a memorandum from Niles Rosen, MD, medical director for CCI, confirms that it is appropriate to bill 94010-59 on the same day as 94070 if normal results from spirometry are the reason for the subsequent methacholine test. Commercial payers also may allow pulmonologists to report 94010 with 94070.
Initiating Treatment
Once a diagnosis of asthma has been confirmed (493.00-493.91), the pulmonologist will choose from several treatment options. Occasionally, a pulmonologist conducts tests to determine which substances the patient is allergic to. "With this information, we instruct patients on how to control their environment, if possible, and minimize allergic reactions that may [...]