Revenue Cycle Insider

Hint: Try to specify unspecified codes.

One of the most common pulmonary function tests (PFTs) is spirometry, but for pulmonology practices to receive payment for their services, more work needs to be done than just assigning the correct CPT^® code. If the physician’s documentation doesn’t specify the patient’s respiratory disease or symptoms, then your claim could be denied.

Learn how you and your providers need to show medical necessity to receive spirometry reimbursement.

Refresh Your Spirometry Knowledge

Procedure breakdown: Pulmonologists use spirometry to measure how much air the patient inhales and quickly exhales. Providers perform the test to assess the patient’s condition and differentiate between restrictive respiratory diseases and obstructive respiratory diseases.

Obstructive lung diseases make it difficult for patients to exhale all of the air in their lungs. Examples of obstructive respiratory diseases include chronic obstructive pulmonary disease (COPD) and asthma.

Restrictive lung diseases prevent patients from fully filling their lungs with air because the lungs become stiff and are unable to expand completely during inhalation. Examples of restrictive lung diseases include interstitial lung disease and sarcoidosis.

Patients may exhibit several symptoms of obstructive and restrictive lung disease when they seek medical attention. These symptoms can include:

• R06.02 (Shortness of breath)
• R05.- (Cough)
• R06.2 (Wheezing)
• R07.1 (Chest pain on breathing)
• R53.83 (Other fatigue)
• R09.3 (Abnormal sputum)

The pulmonologist will order a pulmonary function test (PFT) for further evaluation of the patient’s condition if the physician observes any of the symptoms listed above during the physical examination. However, the provider’s documentation must show the medical necessity to report 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation).

Show Medical Necessity for the Exams

Without documented and credible medical necessity, the pulmonologist won’t be able to receive proper reimbursement for spirometry services. You need to turn to the ICD-10-CM code set to assign the correct diagnosis codes to show medical necessity.

Example: An established patient presents to their pulmonologist’s office with complaints of a harsh cough with sputum, wheezing, chest discomfort, and shortness of breath. The patient has a history of COPD. After capturing a history and physical examination, the pulmonologist performs spirometry and interprets the results. The provider diagnoses the patient with COPD with bronchitis.

For this example, you’ll need to select the codes that reflect the diagnosis. Starting with COPD, you’ll look to parent code J44.- (Other chronic obstructive pulmonary disease). The parent code carries a 4^th character required icon, which provides greater specificity for the disease. You’ll assign J44.0 (Chronic obstructive pulmonary disease with (acute) lower respiratory infection) instead of the unspecified COPD code, J44.9 (Chronic obstructive pulmonary disease, unspecified), so your claim shows an accurate reason for the spirometry test.

You’ll also notice the Code also note listed under J44.0, which instructs you to assign an appropriate code to identify the lower respiratory infection. The provider diagnosed the patient with COPD with bronchitis, so you’ll assign J20.9 (Acute bronchitis, unspecified) to identify the bronchitis infection. That is, unless the physician documented that the bronchitis was caused by another infection, such as respiratory syncytial virus (RSV), which is coded to J20.5 (Acute bronchitis due to respiratory syncytial virus).

Signs and symptoms: Using a definitive diagnosis to show the medical necessity is nice, but using signs and symptoms is just as acceptable in many cases if the diagnosis hasn’t yet been confirmed. According to ICD-10-CM Official Guidelines, Section I.B.4, you should code the signs and symptoms “when a related definitive diagnosis has not been established (confirmed) by the provider.”

In the example listed above, you’d assign J44.9 to report the encounter due to the patient’s history of COPD. However, the pulmonologist performed the spirometry testing to assess the patient and see if the symptoms are related to the patient’s COPD or is due to a new undiagnosed condition. If the physician is doing testing as additional workup for the symptoms, report R06.02 and R06.2 as the indications for spirometry.

Certain private payers may deny your claim solely because you assigned an unspecified diagnosis code, such as J44.9 (when applicable to report). Check payer policy to see if they prefer the symptomatic indication for the test, since this would better explain the current need for testing.

“It is important to distinguish between surveillance studies for a patient with COPD [e.g., J44.9] and studies performed because of escalating symptoms and determining the issue causing them [e.g., R06.02, R06.2, etc.],” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Use Caution When Assigning Unspecified Codes

Situations may arise when your only coding option is to use one of the unspecified diagnosis codes. While the code descriptors may feature the word, “unspecified,” you still need to identify the patient’s condition.

Scenario 1: An established patient presents to their pulmonologist with shortness of breath, fever, chills, cough, and an abnormal amount of mucus. The provider performed a physical examination and spirometry to assess the patient’s condition. The patient has a longstanding history of documented bronchitis. After reviewing the results of the spirometry test, the pulmonologist diagnoses the patient with unspecified chronic bronchitis.

In this scenario, the documented diagnosis doesn’t show the medical necessity for spirometry. “J42 [Unspecified chronic bronchitis] is not a diagnosis that would support medical necessity according to two of the bigger Medicare Administrative Contractors [MACs] for the Centers for Medicare & Medicaid Services [CMS],” says Julie Davis, CPC, COC, CRC, CPMA, CPCO, CDEO, CEMC, AAPC Approved Instructor, compliance senior manager for Honest Medical Group. The documentation needs to specify the type of bronchitis, so you can assign the appropriate diagnosis code. Your claim with spirometry reported is more likely to be approved if it includes whether the patient is experiencing obstructive chronic bronchitis (J44.9) or chronic bronchitis due to smoking (J41.0, Simple chronic bronchitis).

The physician provided insufficient documentation in this scenario. You should query the provider following your practice’s guidelines for queries since the fever and chills accompanied the shortness of breath and increased mucus production. Following the query, the pulmonologist may clarify that the symptoms warrant an acute on chronic bronchitis diagnosis, which is coded to J20.9 (Acute bronchitis, unspecified).

Once again, the pulmonologist performed the testing to assess if the symptoms were caused by the patient’s chronic bronchitis or if the symptoms were due to a new undiagnosed condition. The documentation should explain if the testing was performed for surveillance of their existing chronic condition or to diagnose the escalating symptoms. This will assist in assigning the proper diagnosis code for the test on the claim.

The acute on chronic bronchitis diagnosis more accurately represents the patient’s complaints and supports the reason for the spirometry testing. Sometimes, queries or feedback during training can assist physicians with understanding how their documentation supports proper coding.

Identify Combination Codes to Support Spirometry

You may encounter visit notes where the pulmonologist documents that an acute illness affects the patient’s longstanding condition. In these cases, one diagnosis code might be the correct option over reporting multiple codes.

Scenario 2: A patient who suffers from asthma visits a pulmonology clinic while experiencing wheezing, chest pain, and coughing. After a physical exam and spirometry testing, the pulmonologist documents their findings and documents a diagnosis of asthma with acute exacerbation.

In this scenario, the documentation is sufficient to support the medical necessity for spirometry. Code J45.41 (Moderate persistent asthma with (acute) exacerbation) is a complete code with the correct number of characters for the code category.

“We expect the clinician to document [the full diagnosis], so code J45.41 can be used. It wouldn’t be appropriate for the provider to only document asthma, nor would it be appropriate to report J45.909 [Unspecified asthma, uncomplicated],” says JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager of the Children’s Health Network in the Minneapolis/St. Paul, Minnesota area.

Remember: Payers may identify certain respiratory symptoms as medical necessity for ordering spirometry if the patient doesn’t have a formal diagnosis of a lung disease like asthma or COPD. Other times, the spirometry test results aren’t clear enough for the pulmonologist to issue a definitive diagnosis, and they might need to perform additional testing, such as a chest X-ray, to conclude the diagnosis.

Important: If the patient does have a chronic lung disease, then the physician needs to identify if the illness is acute or not, so the documentation illustrates that the purpose of the visit is routine surveillance studies or for diagnostic services.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC