Pulmonology Coding Alert

Many physicians who initially experienced denial for spirometry (94010) when they billed it with a pulmonary stress test (94620 or 94621), never try billing the two together again, thereby missing some legitimate payment opportunities. You shouldnt do it if the spirometry is used as a baseline for the pulmonary stress test, but you should be able to bill for it if the spirometry was the initial diagnostic and indicated a need for something more comprehensive, says Susan Callaway-Stradley, CPC, CCS-P, a coding consultant in North Augusta, S.C.

Theres a major problem with disallowing reimbursement for a spirogram and pulmonary stress test done on the same day, says Walter J. ODonohue Jr., professor and associate dean for graduate medical education and chief of pulmonary critical care at Creighton University in Omaha. HCFA is saying that the tests measure the same things, which is not true at all.

Sometimes Both Tests Are Needed

ODonohue says the spirogram itself may determine whether more testing is needed. He points out that spirograms and pulmonary stress tests measure different parameters. If you are going to assess a patient thoroughly, you look at spirometry as well as at stress tests, ODonohue says. Its like doing an EKG and also doing a cardiac echo youre looking at entirely different measurements. When youre doing spirometry, youre looking for restrictive or obstructive lung disease and attempting to quantify it. A stress test is more of a measure of the integration of heart and lung function and how well patients utilize oxygen and produce CO2. These are different parameters and they tell you different things. He points out that an adequate patient workup frequently calls for doing both, and requiring that spirometry and stress testing be done on different days often creates a hardship for the patient.

If a patient is referred to ODonohue with shortness of breath (dyspnea, 786.xx), and when he tests for pulmonary function he finds severe obstructive lung disease, the disease explains the shortness of breath, and a complex stress test is needed. But, if a patient has severe obstructive lung disease and Im going to be treating them, ODonohue says, I might want to do a simple stress test just to see how far they can walk and whether they desaturate and what happens to their heart rate, so Ill have a baseline for monitoring their disease. Spirometry is more likely a screening tool for the complex stress test than for the simple one. ODonohue says, however, usually its necessary with any stress test to look at all the parameters of pulmonary function.

According to ODonohue, You need a baseline measurement of activity level even for patients with known lung disease who are entering a pulmonary rehabilitation program. An example of a simple pulmonary stress test (94620, pulmonary stress testing; simple [e.g., prolonged exercise test for bronchospasm with pre- and postspirometry]) for entrance into a pulmonary rehabilitation program is a six-minute walk. He adds that during the simple pulmonary stress test, parameters such as distance, heart rate and shortness of breath should be assessed as well as saturation.

The complex stress test (94621, pulmonary stress testing; complex [including measurements of CO2 production, O2 uptake, and electrocardiographic recordings]) usually is more of a diagnostic stress test to correlate metabolic, pulmonary and cardiac function and to assess PF.

Patricia A. Booth, RN, BS, who writes the coding book for the American College of Chest Physicians, concurs that sometimes both are called for. I think the issue is that you do the spirometry for a different reason than you do the pulmonary stress test, she says. You might do a spirometry, then find that you have to do a stress test because the results of the spirometry indicate that indeed there is minimal lung disease and you need to go a little further in trying to find out the cause of the patients shortness of breath.

Callaway-Stradley says that under certain circumstances payers will recognize (the need for) and pay for both. Its an important coding issue. Coders need to know there are times when it is appropriate to bill both services on the same day.