Pulmonology Coding Alert

Pulmonologists and allergists often use methacholine (J7699) provocation challenge) tests (94070) to determine if a patient suffers from respiratory diseases such as asthma (493.xx). These tests indicate if a patient has airway hyper-responsiveness, which is characteristic of bronchial asthma (491.2x). Spirometries (94010) are performed after each methacholine inhalation to measure the patient's airway responsiveness and to determine if the patient exhibits a bronchospastic response (519.1x). Proper reimbursement for methacholine provocation and the accompanying spirometry requires adequate documentation and knowledge of what can be coded.

Two different codes apply to methacholine challenge testing, which can be used at the same time.

Code 94070 (Prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics) can be divided into a technical and professional component. For example, if the physician supervises and interprets the test in a hospital pulmonary function testing lab (PFT), he or she bills the professional component or interpretation with 94070 and appends modifier -26 (Professional component). The professional component (94070) may occur during an office visit, and then the lab or hospital bills the technical component by appending modifier -TC (Technical component) to 94070 if the lab administered the test. If the professional and technical components were performed by the physician's office, both can be billed by the physician reporting 94070 with no modifier.

Code 95070 (Inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds) cannot be divided into technical and professional components. It is for the administration of the methacholine in the inhalation bronchial challenge test. Whoever administers the drug bills for it. If the administration occurs in a hospital setting, the hospital bills for the administration of the methacholine (95070). If the administration is performed in the physician's outpatient office or lab, then the physician bills for it. In addition, whoever administers the test and methacholine also can bill for the methacholine (J7699).

An established patient presents with shortness of breath (786.05). A pulmonologist examines the patient (99211-99215) and appends 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 appropriate E/M code. An evaluation of the patient's labored breathing is done. A spirometry (94010) is performed to measure the patient's respiratory function, which is near normal. The patient's symptoms lead the pulmonologist to suspect a possible asthmatic condition (493.00, 493.10, 493.20, 493.90), so a methacholine challenge test is ordered. The methacholine is administered in the doctor's office, with the time of the administration noted in the patient's record. To measure the patient's bronchial response after the methacholine administration, another spirogram is done as part of the methacholine test.

Increasing doses of methacholine are given, with additional spirometric readings, which are needed to observe the response to escalating concentrations of methacholine. Because the pulmonologist interprets the test and his or her staff administers the methacholine, billing 94070 and 95070 is appropriate. The physician must prepare a written report of the test, including the interpretation of the findings. For example, a 20 percent drop in FEV1 (forced expiratory volume in one second) is recorded and noted in the patient record. Upon examination, the patient exhibits audible wheezing after the second dose of methacholine, which is indicative of airway hyper-responsiveness.

"We do a spirometry after each dose of methacholine," says Rona Hamill, a billing specialist at Asthma and Allergy Center in Papillion, Neb. "We are looking for a patient's FEV1 to drop 20 percent. So that could involve as many as six spirometric readings, depending on how the patient responds."

If the patient develops bronchospasms as a result of the test, a bronchodilator can be administered to reverse the bronchospasm (94640) and be billed with modifier -59 (Distinct procedural service).

Spirometric readings (94010) initiated after the methacholine is administered are always included in 94070. Subsequent spirometric determinations also cannot be billed because they are bundled into 94070. If the spirogram is performed before the methacholine test to determine whether bronchospasm (519.x) is present, however, it can be billed with modifier -59. The modifier alerts the insurance carrier that the methacholine challenge test and the spirometries are distinct and separate services.

Initially, CPT bundled a spirogram (94010) and bronchodilator (94640) into 94070. That changed, largely due to the efforts of Walter J. O'Donohue, MD, FCCP, chairman of the CPT committee of the American College of Chest Physicians (ACCP) and a representative to the AMA CPT advisory committee for ACCP and his colleagues. "Now, if you have a patient who is short of breath (786.05) and a spirogram (94010) is performed on the same day, the spirometry can be billed with modifier -59," O'Donohue says. "Also, if the spirogram is normal, a methacholine test may be necessary to elicit a bronchospasm. If a patient develops a bronchospasm as a result of the test, a bronchodilator may be administered (94640-59)."

You should document the test's medical necessity if Medicare or a private carrier denies a claim for spirometric readings. The physician must record the date and time the methacholine test is administered and spirometries that took place, along with the medical necessity for the methacholine test, such as suspected asthma.

CPT allows multiple spirometric readings with 94070 for patients who exhibit signs of suspected asthma, respiratory abnormality like dyspnea, hyperventilation, wheezing and shortness of breath, and cough. Detailed documentation is critical to ensure reimbursement and helps if appeals are initiated following a claim denial.

"I often will send in a copy of the spirometries and notes from the exam that show the patient was short of breath (786.05), as well as another note that tells the dosage of methacholine,"

Hamill says. "Our nurses also document whether that person had problems with the dose of methacholine." Hamill suggests submitting a copy of the methacholine product insert to an insurance carrier that has denied a claim. For example, if provocholine is administered, send a copy of the insert and highlight the indications and usage section to show that the drug was used to determine bronchial airway hyper-responsiveness with a patient who did not have clinically apparent asthma.

"By sending this, it helps tell the insurance company that upon examination the doctor could not determine if a patient had asthma without the test," Hamill says.

Always append modifier -25 to the E/M service a physician performs with a procedure or test. It indicates that the patient's condition required a separately identifiable and billable E/M service.

In our earlier example of a patient who presents with shortness of breath (786.05), the pulmonologist examines the patient, reporting codes 99211-99215 billed with modifier -25 and 94010 for the initial spirometry to measure the patient's respiration. Modifier -25 also may apply when reporting an E/M service in addition to 94070 and 95070. You should ask your local carrier about using modifier -25 to report E/M services with 94070 and 95070 because not all carriers require it when billing for E/M in this situation.

"My approach is to always use modifier -25 if I am doing an E/M service and a procedure or test," O'Donohue says. "The worst thing a carrier can say is you didn't need this. Without the modifier, the carrier can say we aren't going to pay you."