Pulmonology Coding Alert

Caveat: Don't mix 94010 and 94060, or you'll be in trouble.

If you think dealing with pulmonary function test (PFT) codes is as easy as 1-2-3, you might be counting the chickens before they are hatched. PFT consists of the following procedures: Spirometry, lung volume, diffusion capacity, lung compliance and pulmonary  studies during exercise testing. Not familiarizing yourself with the appropriate CPT codes for PFT could send you down the audit line.

Typically, you would come face-to-face with billing a PFT when your pulmonologist sees a patient with suspected or known lung disease. The physician needs a meticulous history and physical examination in order to verify the patient's lung condition and differentiate among disease entities.

Example: A 57-year-old man with heavy smoking history presents to the pulmonologist's office for the first time with shortness of breath (786.05). On clinical examination, she  shows signs of underlying emphysema (492.8, Other emphysema). The pulmonologist orders PFTs to define the severity of her obstructive lung disease.

Check out the following tips to avoid unnecessary headaches.

1. Start With Fundamental Test

Pulmonologists would routinely use spirometry as an objective method to assess functional changes in patients. This test provides rapid and reproducible measurement of lung volumes and flow rates, and covers CPTs 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation), 94375 (Respiratory flow volume loop), and 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration). It can quickly alert the physician to an obstruction of airflow, and confirm a suspected diagnosis.

How it's done: The provider asks the patient to place the spirometer in their mouth, making sure no leaks are present. He blocks the patient's nose with a properly fitted nose clip. He instructs the patient to breathe normally until a constant end tidal breath is established and  the vital capacity maneuver initiated. After maximum inspiration is achieved, the provider asks the patient to blow air out as forcefully and rapidly as possible for a minimum of 10 seconds. If the physician requires information on inspiratory flows, the provider then asks the patient to forcefully inhale to a point of maximal inspiration. The physician repeats the maneuver until three acceptable and reproducible tracings are obtained.

Here's an example: Suppose you're billing an encounter with both allergy testing and spirometry done on an asthmatic patient (two encounters performed on the same day). The physician performed spirometry to test the patient's lung capacity after evaluating the patient's current respiratory status. In this case, you should report: 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for the  separately identifiable E/M that the physician performed for the diagnosis and evaluation of the patient's underlying respiratory condition, emphysema (492.8). You would report spirometry with 94010 with 786.05 as the primary reason for the testing.

2. Pick Out The Right PFT Combo For The Right Purpose

Remember this one important catch in billing for PFT: Although you might get the ppropriate test correctly, getting the CPT right is still a challenge because of the many codes comprising a particular test (i.e., spirometry, lung volume). Other tests that your pulmonologist might include in a PFT series are:

• Lung Volume -- 4240 (Functional residual capacity or residual volume: helium method, nitrogen open circuit method, or other method), 94260 (Thoracic gas volume), and 94360 (Determination of resistance to airflow, oscillatory or plethysmographic methods)
• Diffusion Capacity -- 94720 (Carbon monoxide diffusing capacity [e.g., single breath, steady state])
• Lung Compliance -- 94750 (Pulmonary compliance study [e.g., plethysmography, volume and pressure measurements])
• Pulmonary Stress Testing -- 94620 (Pulmonary stress testing; simple [e.g., 6- minute walk test, prolonged exercise test for bronchospasm with pre- and postspirometry and oximetry])

Your pulmonologist can order some of these tests together in a code set, depending on what procedure(s) the physician wants to perform during a PFT. If you know how to use these code sets properly, you can maximize your reimbursement for a PFT in your office. This table shows three sample code sets that you can report, the CPTs corresponding national rate, and the estimated profits your practice can collect for each set:

Note: These codes differ based upon the type of machine the provider uses and the information he gathers. Additionally, be careful about reporting codes simply because you want a higher reimbursement. Remember, you should always base coding on the documentation. Otherwise, your claim would be fraud.

For instance, a patient with chronic obstructive pulmonary disease (COPD, 496) -- presents to the office with a variety of symptoms, including shortness of breath, wheezing, and breathlessness. The pulmonologist decides to perform numerous inoffice tests to properly diagnose the severity of the disease, including bronchospasm evaluation, diffusing capacity test, and thoracic gas volume test. He also orders a chest x-ray. In this case, you should report the following:

• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes faceto- face with the patient and/or family.)
• 94060 for the bronchospasm evaluation;
• 94720 for the diffusing capacity test;
• 94260 for the lung volume test;
• 491.21 (COPD with acute exacerbation) linked to the CPTs.

The radiologist should bill for the x-ray (71010, Radiologic examination, chest; single view, frontal), but you should include your physician's review of the x-ray interpretation in your documentation.

Helpful: The bronchospasm evaluation (94060) involves spirometry (94010) taken before and after your physician administers bronchodilation (94640, Pressurized or nonpressurized inhalation treatment for a  obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) to dilate the airways. This means you cannot report both spirometry and bronchospasm tests on the same day.