Pulmonology Coding Alert

Question: We billed a patient who underwent PFT and inhalation test with albuterol with 94060, 94200-59, 94375, 94760, J7613, 94727, 94728 and 94729. We only get paid for 94060 and 94200 along with the J code. Have we been paid correctly or am I doing something wrong?

New Jersey Subscriber

Answer: You should know that when performing pulmonary function tests (PFT), some codes for PFTs are bundled and will not be paid out separately. Without the report, we cannot tell you if your codes are correctly selected. However, we can comment on what you have reported.

In the list of codes that you have mentioned above, the codes 94375 (Respiratory flow volume loop) and 94728 (Airway resistance by impulse oscillometry) are bundled into 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) as per Correct Coding Initiative (CCI) edits and cannot be reported separately under any circumstances.

94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination) has a code status "T" in CMS physician fee schedule which means the code is bundled into any same day service and therefore should not be reported with other procedures. This code, if reported with any other CPT^® code on same day, will be rejected by payers.

So you are left with 94060, 94729 (Diffusing capacity [e.g., carbon monoxide, membrane] [List separately in addition to code for primary procedure]), 94727 (Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes), 94200 (Maximum breathing capacity, maximal voluntary ventilation) with modifier 59 (Distinct procedural service), and J7613 (Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg). 94729 can be reported as add-on code with 94060, as per AMA instruction. 94727 has no bundling with any of these codes, but you need to check documentation if you can bill this code separately.

Since these codes are related to PFT and PDT (pulmonary diagnostic testing), there is a chance that payers will bundle some of codes with the main code. You can submit documentation to prove the medical necessity and the reason for the CPT^® codes that you have reported.