Pulmonology Coding Alert

Along with the bronchodilation service code, you can bill for the bronchodilator medication under certain circumstances using the appropriate HCPCS code, such as J7618 for Albuterol. However, when the physician performs the test in a hospital, you would not bill for these supplies, Tiesmeyer says.

The pulmonologist will often need to order various other diagnostic tests and PFTs. He can order a chest x-ray and diffusing capacity test, such as 94720 (Carbon monoxide diffusing capacity [e.g., single breath, steady state]). Another option is a lung volume test like 94260 (Thoracic gas volume) or 94350 (Determination of maldis-tribution of inspired gas: multiple breath nitrogen washout curve including alveolar nitrogen or helium equilibration time). However, Medicare considers these PFTs bundled with spirometry.

When performing these tests on the same day as spirometry, only report 94010. Some practices mistakenly believe you can bill for 94200 (Maximum breathing capacity, maximal voluntary ventilation) with spirometry if you provide adequate documentation of the test's necessity. But Tiesmeyer says that you cannot bill for 94200 with spirometry, since it is bundled. The only exception is if it was performed at a separate session on the same day, since the CCI edit for 94200 has a "1" indicator. This means you can use a modifier to unbundle the code under appropriate circumstances.

The pulmonologist may order pulse oximetry, 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination), and blood gas testing (82803-82810) depending on the severity of the disease, says Terri McCleskey, billing coordinator at the Georgia Pulmonary Group, Snellville, Ga. However, most carriers consider pulse oximetry as incidental and will not pay for this service separate from an E/M service. Tiesmeyer says she  only submits pulse oximetry to Medicare if there is nothing else performed on the same day. If it is done with other tests or services payable under the Physician Fee Schedule, she does not bill for it. Also, you will not report laboratory services unless you have an in-house laboratory.

Coding becomes complicated when the pulmonologist decides to perform a pulmonary stress test, such as 94620 (Pulmonary stress testing; simple [e.g., prolonged exercise test for bronchospasm with pre-and post-spirometry). He may order this test to assist in diagnosis if the initial spirometry test results are inconclusive. You may find it helpful to append modifier -59 (Distinct procedural service) to differentiate the stress test from the initial spirometry.

According to McCleskey, you need to remember to append modifier -26 (Professional component) if you do not own the PFT equipment. However, bill for the entire service when you use your own equipment, which will increase your reimbursement.

Given the increased level of medical decision-making evident in the numerous tests ordered and reviewed, you may find support for reporting a level-three or -four E/M visit code. Assuming the history, physical, and MDM meet requirements, you could report 99204 or 99214 depending on whether the patient is new or established. "The E/M code you use is based upon the physician's dictations concerning the visit," Tiesmeyer says.

Many factors come into play when determining the E/M level, McCleskey says. For example, a patient may come to the pulmonologist from another doctor having had previous chest X-rays, chest CTs, and PFTs. When a patient is referred or presents with "possible emphysema," you may be justified in billing a higher-level visit because the pulmonologist must determine the severity of the emphysema and how to treat the disease, along with performing various tests and interpreting the results.

CPT states that the performance and/or interpretation of diagnostic tests or studies ordered during a patient encounter are not included in the levels of evaluation and management services. Therefore, you can report the E/M service code separately from any diagnostic services performed that are not bundled into the E/M service or other codes. You should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

For example, a 65-year-old new patient presents in the office with symptoms of shortness of breath, wheezing and breathlessness. The pulmonologist takes a comprehensive history and a comprehensive examination, and performs MDM of moderate complexity. The MDM includes the ordering of several PFTs (94060, 94010, 94200, 94260, 94720). Remember that CCI bundles 94010 and 94200 into 94060. The physician thoroughly documents the medical necessity for each test. You would report the following: