Pulmonology Coding Alert

Mythbusters:

Get the Truth About These 3 Mind-Bending PFT Coding Myths

Published on Mon Feb 07, 2022

Find out if you can code demonstration and treatment together.

The dizzying descriptors and perplexing guidelines of pulmonary function testing (PFT) codes can confuse the most seasoned coders. However, if you’re able to cut through the bundling confusion, you could avoid claims denials and receive proper reimbursement.

See if you can separate fact from fiction by dispelling these common PFT coding myths.

Myth 1: Report Spirometry Separately From Measurement and Volume

The confusion between Medicare’s National Correct Coding Institute (NCCI) rules about Procedure-to-Procedure (PTP) edit pairs and CPT^®guidelines gives this myth life. But CPT^®guidelines surrounding the Pulmonary Diagnostic Testing, Rehabilitation, and Therapies provide very detailed and specific instructions regarding spirometry procedures, vital lung capacity measurements, and volume.

Diving into the CPT^®guidelines, we find that 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation) and 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) include these codes:

94150 (Vital capacity, total (separate procedure))
94200 (Maximum breathing capacity, maximal voluntary ventilation)
94375 (Respiratory flow volume loop)

“Spirometry measures expiratory airflow and volumes, and is the basis of most other pulmonary function tests. Therefore, measurement of vital capacity is a component of spirometry, as is flow-volume loop measurement,” says Melanie Witt, RN, MA, an independent coding consultant and AAPC Consulting Editor from Guadalupita, New Mexico.

What this means: If you have provider documentation listing spirometry, vital capacity, breathing capacity, and flow volume, you need to report only 94010 or 94060, instead of three separate codes.

Additionally, the code set’s parenthetical statements for 94150, 94200, and 94375 instruct you to not report the codes in conjunction with 94010 or 94060. However, if a provider performs the procedures separately from spirometry tests, then you should report the appropriate codes separately.

When you explore the NCCI PTP edit pairs, you’ll find 94150, 94200, and 94375 are bundled into 94010 and 94060. The edit pairs 94010/94375 and 94060/94375 have a modifier indicator of “0,” which means the edit pairs can never be unbundled. The modifier indicator column has a “1” listed for the 94150 and 94200 edits, which means modifier use may be appropriate to unbundle those codes from 94010 and 94060. For example, if your provider performed maximum voluntary ventilation (MVV) in a separate encounter from the PFT, you’d append a modifier such as 59 (Distinct Procedural Service) to the appropriate procedure code, such as 94200.

When trying to figure out the bundling issues, you also have to keep in mind the code status. For example, the edits 94010/94150 and 94060/94150 list a modifier indicator of “1,” but 94150 has a “Bundled” status (Payment for covered services are always bundled into payment for other services not specified) on the Medicare Physician Fee Schedule (MPFS). Code 94150 also has a Medically Unlikely Edit (MUE) of “0” for practitioners, which means Medicare will deny 94150 claim lines.

Important: The codes listed above aren’t the only ones you can report separately. Be sure to capture every applicable code as it pertains to the report to ensure accurate reimbursement.

Myth 2: No Codes Exist for Therapeutic Respiratory Tests

While several pulmonology tests exist to help diagnose a patient’s condition, one test can act as both a diagnostic test and a treatment. CPT^®code 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) features the terms “therapeutic purposes” and “diagnostic purposes” in the descriptor, which allows you to report testing and treatment.

Clock management: Code 94640 is intended for short-term inhalation treatments, generally lasting less than one hour. According to the September 2015 issue of CPT^®Assistant, if you need to report additional treatments with the same code on the same day of service, you should append the code with modifier 76 (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional).

And any service that extends to a full hour requires you to report 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour) or +94645 (...; each additional hour (List separately in addition to code for primary procedure)) with 94644 for each additional hour of service.

Myth 3: Treatment and Equipment Demos Can’t Be Coded Together

NCCI edits bundle many services into therapeutic and diagnostic inhalation treatment code 94640. One of those bundled codes is 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

Since 94664 is bundled into 94640, you’re typically unable to report the two codes together if a provider or clinical staff member provides treatment and demonstrates the use of equipment during the same session. But you can report each code separately if the encounter and documentation meet certain conditions.

Scenario 1: Your pulmonologist sees a patient for their asthma and provides treatment via a nebulizer. The patient’s condition stabilizes, and the physician discharges them with the device for continued treatment at home. The patient returns the next day because they’re unsure how to operate the nebulizer. The physician spends 15 minutes walking the patient through how to use the device when they get home.

Scenario 2: A patient comes into your pulmonology practice experiencing an exacerbation of their chronic obstructive pulmonary disease (COPD). The pulmonologist administers an intermittent positive pressure breathing (IPPB) device to help stabilize the patient. Before the patient leaves, the physician prescribes a metered dose inhaler and demonstrates the proper use of it to ensure the patient can continue treatment at home.

In the first scenario, the patient returned on a different day to receive education on how to use their treatment. Scenario 1 does not require a modifier since the services occurred and get reported on two separate dates.

In Scenario 2, you can unbundle 94664 from 94640 using a modifier because the patient received one treatment in the office and then a different one to perform at home. The NCCI PTP edits list 94664 as a column 2 code to 94640 with a modifier indicator of “1,” which makes it possible to report both codes with a modifier to override the edit when appropriate. For instance, depending on your payer’s preferences you may append modifier 59 to 94664.

Remember: Make sure your provider’s documentation backs up that either the two services occurred at different times or the treatment and demonstration involved different devices. This clinical documentation will help prove it was medically necessary to unbundle the services.