Pulmonology Coding Alert

Ignoring CCI bundles can put the brakes on all your coding efforts.

Today’s fitness conscious world has brought on a new problem — exercise-induced pulmonary stress. Your pulmonologist will resort to tests known as Pulmonary stress tests (PST, a.k.a. exercise testing) whenever she comes across patients complaining of breathing problems and/or wheezing they encountered after strenuous exercising. You can pick out one from the two code options that describe a PST, but what’s paramount is discerning the difference between the two codes.

Other than the fact that 94621 (Pulmonary stress testing; complex [including measurements of CO2 production, O2 uptake, and electrocardiographic recordings]) needs more equipment, how can you decide when to use that as against 94620 (Pulmonary stress testing; simple [e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry])? Go through the tips to maximize your returns on PSTs.

Tip 1: Prove Necessity of the Test With Documentation

Go thoroughly through the pulmonologist’s notes to find pointers for choosing either of the two codes. Look for the following symptoms to justify medical necessity and successful reimbursement for 94620:

• Exercise induced bronchospasm (493.81) or interstitial lung disease (fibrosis), which are only manifested by exercise.
• those experiencing unexplained shortness of breath (518.82), chronic bronchitis and emphysema, pulmonary hypertension, or pulmonary fibrosis
• unexplained dyspnea (786.09)
• chronic cough (464.4)
• wheezing (786.09)
• those undergoing pre-op evaluation for a lung transplant or major lung surgery;
• those subjected to disability evaluation for the severity of an occupational lung disease (e.g., asbestosis); 
• those undergoing evaluation to meet Medicare’s requirement for supplemental oxygen use during exercise.
• Need for information whether the patient’s exercise intolerance is related to pulmonary disease or cardiac disease, lack of lung conditioning or poor effort.
• Initial diagnostic workup, when symptoms, generally dyspnea, are out of proportion to findings on static function (spirometry, lung volume, and diffusion capacity).
• To evaluate patient’s response to a newly established pulmonary treatment regimen.

On the other hand, a complex pulmonary stress test (94621) is justified if the pulmonologist records a suspicion of an underlying cause (cardiac or pulmonary) for a patient’s dyspnea. Needless to say, link these symptom codes in the documentation to your chosen test. Take to consult the list of ICD-9 codes covered as medically necessity to warrant exercise tests.

Tip 2: Know the Difference Simple and Complex PST

Although both PST procedures measure exercise tolerance and the cardiorespiratory responses to the exercise, you will have a clear distinction between the two.

Difference: CPT® code 94621 requires more equipment and has more complexities because it analyzes exhaled gas (CO2 production, O2 uptake) and measures electrocardiographic responses to stress. Facilities nowadays use cardiopulmonary exercise testing [CPX] systems. Modern CPX systems allow for the analysis of gas exchange at rest, during exercise, and during recovery and yield breath-by-breath measures of oxygen uptake (Vo2), carbon dioxide output (Vco2), and ventilation (Ve).In addition, this procedure also records data on peak cardiovascular and ventilatory responses. The pulmonologist has to record his findings in a report after analyzing and interpreting the results of these tests.

You have a bunch of codes that you can include for the specific exhaled gas analyses along with 94621. 

Case: A pulmonologist recommends arterial blood gas analysis during the complex pulmonary stress exercise. Here, you can bill the blood draw additionally with 36600 (Arterial puncture, withdrawal of blood for diagnosis), and analysis is reported by the lab with 82803 (Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 [including calculated O2 saturation]) or 82805 (Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 [including calculated O2 saturation] with O2 saturation, by direct measurement, except pulse oximetry).

Tip 3: Beware of CCI Bundles

The Correct Coding Initiative (CCI) bundles 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation), 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration), and 94070 (Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents [e.g., antigen(s), cold air, methacholine]) with both simple and complex PST. 

For example: A 64-year-old male with COPD presents to the physician with increasing dyspnea on exertion. The pulmonologist orders a spirometry with bronchodilator and a simple exercise test. You have now a selection of codes among 94010, 94060 and 94620.Your physician may not be able to charge for all of these codes since CCI bundles these tests. Spirometry with bronchodilator is combined into 94060.

According to Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania, “if 94060 was performed on the same day, at a separate session, which yielded little information to determine the patient’s exacerbated condition, and warranted further assessment through a simple pulmonary stress test, modifier 59 (Distinct procedural service) is necessary to indicate that the bronchodilation responsiveness was separate from the simple exercise test.” In this particular case your best bet would be billing 94620, 94060-59.

However, if the pulmonologist performed bronchodilator responsiveness as a component of the simple pulmonary stress test, you can only report 94620. This is especially true for 94620 as the test is commonly measured along with 94010 and 94060. 

Tip 4: Highlight All Tests to Steer Clear of 94761

According to the descriptor for CPT®, 94620 can include a six-minute walk test (6MWT) with oximetry in the test. The payers will only accept the code if all prescribed aligned tests such as heart rate, blood pressure, oxygen saturation are reported at rest, during exercise, and during recovery. You may risk getting the six minute walk test labeled as 94761 (Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations [e.g., during exercise]) if you don’t diligently document objective ventilatory assessments should be reported with CPT®. Without the appropriate documentation, some payers might mistake your 94620 claim for multiple determination of oximetry.

A 6MWT measures how well a patient performs during exercise and the distance he is able to achieve.A pulmonologist may depend on the walk test to decide on the necessity to prescribe oxygen during ambulation and exercise for the patient. Chronic obstructive bronchitis (491.20), emphysema (492.8), and pulmonary hypertension (416.0) are some of the conditions that may warrant a walk test.