Pulmonology Coding Alert

Question: A 55-year-old new patient who has been smoking for 30 years with shortness of breath presented to our pulmonologist for consult. The physician performed a detailed history and an expanded problem-focused exam, and decided that spirometry would help diagnose COPD. The patient had non-optimal readings on the first spirometry, so the physician administered albuterol and re-performed the spirometry. Readings from the second test were greatly improved. The pulmonologist diagnosed the patient with intermittent asthma and probable COPD. Which codes should we report?

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Answer: For this encounter, you should report the following codes:

• 99241-99245 (Office consultation for a new or established patient office ...) for the consult services (if accepted by the payer) or 99201-99205, based on the key components of history, exam, and medical decision making;
• 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) for the albuterol-induced spirometry;
• J45.21 (Mild intermittent asthma with (acute) exacerbation) because the patient is having an acute exacerbation (shortness of breath). A secondary code is not necessary in this case because shortness of breath is intrinsic to asthma and the COPD is not a definitive diagnosis.
• J7609-J7613 (Albuterol, inhalation solution,...) for the bronchodilator medication, such as Albuterol, if your pulmonologist performs the test in the office.

Hint: The correct code here is 94060 because the spirometry has turned into a bronchospasm test since the physician used an albuterol inhaler during the evaluation. The bronchospasm evaluation (94060) involves spirometry (94010) taken before and after your physician administers bronchodilation to dilate the airways.