Pulmonology Coding Alert

Hint: Ask about test details when your pulmonologist orders PFTs

Pulmonologists often order pulmonary function tests (PFTs) for patients who present to their practices with symptoms such as wheezing and shortness of breath. With so many different pulmonary function tests and so many codes to go along with them, your job can be challenging. Read on to discover expert tips that will keep you from reporting incorrect codes.

Don’t Report 94010 and 94060 for the Same Day

Two common PFTs that pulmonologists perform are baseline spirometry and spirometry after administration of a bronchodilator. You should use 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurements[s], with or without maximal voluntary ventilation) to report a baseline spirometry test. For spirometry after the administration of a bronchodilator, you should report 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post- bronchodilator administration).
 
Because the bronchospasm evaluation involves pre- and post-spirometry, the National Correct Coding Initiative bundles 94010 with 94060. This means that you cannot report them separately when the physician or nurse performs the tests the same day. You should report the single most comprehensive code for the session.
 
Pulmonologists may perform both PFT tests in one day. For example: “When a patient presents with chest symptoms of wheezing, shortness of breath, etc., our physician would most likely order a simple spirometry,” says Mary Beth Wass, MS, CMM, manager of The Asthma & Allergy Center in Papillion, Neb. “If certain measurements were found to be below normal, the patient may be given an inhalation treatment, such as a bronchodilator, followed by another spirometry.” In this case, you should report 94060.

Different Diagnosis Codes Help Methacholine Reimbursement

When your pulmonologist orders a methacholine challenge test for a patient, you should report 95070 (Inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds). Be sure you also report 94070 (Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents [e.g., antigen(s), cold air, methacholine]) for multiple spirometries that measure the methacholine’s impact. You should also submit HCPCS Codes J7674 (Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg) for the methacholine used in the challenge.

If your pulmonologist needs to determine the patient’s breathing disorder, he may perform a methacholine challenge test. In some cases, a physician may schedule a methacholine challenge for those patients who have a history of shortness of breath and wheezing, but who have no documented reversibility in lung functions, Wass says. After completion of the study, the physician may be able to confirm that the patient has reactive airway disease.
 
Beware: If your pulmonologist orders a spirometry and a methacholine challenge during the same visit, you may not be able to code both services. The January 1999 CPT Assistant says: “When 94010 is performed as the initial spirogram, it is usually performed as a preliminary test, the results of which may lead to the performance of a provocative test using methacholine (94070). Therefore, under these circumstances, code 94010 should be reported separately [with modifier 59, Distinct procedural service], in addition to code 94070. However, the subsequent spirometries are considered part of the procedure (94070) itself and should not be individually reported.”

“Some insurance companies do not reimburse us for both procedures if done on the same day,” says Mary Maston, office manager at Champlain Valley Pulmonary Associates in Plattsburgh, N.Y. If the pulmonologist performs spirometry prior to the methacholine challenge and documents the appropriate indications for each of the studies, assigning a different diagnosis code to each study will help you obtain payment more easily. For the scenario above, you would report 94010-59 with 786.05 (Shortness of breath) and 786.07 (Wheezing), and 94070, 95070 with 493.90 (Asthma, unspecified).

The Point of Service Affects Your PFT Coding

You need to consider where a PFT took place to correctly report the test. PFTs have both a professional and a technical component. Therefore, the location of the testing plays a part in how you code these tests.

For instance, when a technologist performs a PFT and the physician provides the supervision and interpretation of the test in a private setting, such as the physician’s office, you can report both the professional and the technical components by using the correct CPT code without a modifier.

If the PFT service takes place in a  facility setting, such as an outpatient hospital, and the pulmonologist interprets the test for the PFT lab, you should report the professional component, and the facility should report the technical component. The physician appends modifier 26 (Professional component) to the PFT code in this circumstance. The facility should attach modifier TC (Technical component).

For example: If your pulmonologist orders a respiratory flow volume test, and the patient undergoes the test in an outpatient hospital setting, you should report 94375-26 (Respiratory flow volume loop; professional component) and the facility should report 94375-TC.
 
Know the Test Specifics

One of the challenges of PFT coding is that there are so many pulmonary function tests and variations on what tests your pulmonologist orders in a PFT request. Unless you’re clear on exactly which specific pulmonary function tests your pulmonologist ordered and performed, you won’t know which codes to report.

“It is a challenge to sort out all of the procedures that are done,” says Cheryl Klarkowski, RHIT, from BayCare Health System LLC in Green Bay, Wis. You can review the documentation and, if you’re not familiar with the tests, speak with the physician, since he is the one who is ultimately responsible for the services reported, and you’ll know exactly which tests the patient had, what should be documented, and which codes you can report.