Pulmonology Coding Alert

Question: We're being asked to perform screening spirograms on patients under consideration for inhaled insulin. It is, in fact, required that the patient have a spirogram before we can prescribe the drug. Our local Medicare carrier does not have a diagnosis in the local coverage determination (LCD) that covers a spirogram for inhaled insulin candidates. Would this be a case for an advance beneficiary notice (ABN), or are we missing something here? We're not sure what we should do, but this is a growing concern as more requests come in. Michigan Subscriber
Answer: Medicare coverage for baseline spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) in patients under consideration for inhaled insulin varies by payer. Some contractors, such as TrailBlazer, cover the tests required for monitoring the effect of drug therapy for medications with the potential for pulmonary toxicity (www.trailblazerhealth.com/Policies/Local%20Coverage%20Determinations/Default.aspx?id=2783). Other Medicare carriers, such as Highmark, recognize the importance of, and cover the tests for, establishing baseline values (www.highmarkmedicareservices.com/policy/partb/m1/m73a.html). Best bet: Ask your Medicare contractors if they will reimburse 94010 for patients under consideration for inhaled insulin. If the contractor will not pay, be sure to get the patient to sign an ABN preprocedure. Non-Medicare payers may choose to follow Medicare, or they may deny all spirometry services absent signs, symptoms, or cardiopulmonary conditions considering them as not reasonable and necessary. Even with coverage policies in place, the contractors may not pay the claim upon initial submission. An insurer may reject the claim, awaiting supporting documentation from the provider, or simply deny the service, leaving the provider to manage his way through the appeal process. Supporting documentation should include the spirometry tracing and physician interpretation, as well as the progress note that identifies the care plan for inhaled insulin therapy.