Pulmonology Coding Alert

Question: Reporting modifiers with E/M service during a pulmonary function test (PFT) always confuses me. Do I add modifier 25 to the E/M code or add modifier 59 to the pulmonary function code?

South Carolina Subscriber

Answer: You're not alone in struggling with the difference between modifiers 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 59 (Distinct procedural service).

Fortunately, CPT 2008 made the distinction much clearer. Modifier 59 can be used only to distinguish one procedure from another procedure. You would use modifier 25 to indicate you have documentation that supports an E/M as significant and separate from the work involved in another service or procedure.

When coding pulmonary function tests and an E/M, Medicare does not require modifier 25, but some third-party payers might.

You would only use modifier 59 when the Correct Coding Initiative bundles two codes but under the circumstances the two are separately reportable.

Example: A 65-year-old woman presents with dyspnea (786.09) and cough (786.2). Your pulmonologist orders a spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation), which comes back normal. He then orders a six-minute walk test (94620, Pulmonary stress testing; simple [e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry). Her pulmonary stress test result is abnormal, demonstrating a decrease in distance and a drop of SpO2 from 94 percent to 88 percent with exercise.

Even though the spirometry tested normal, the patient's history of cough and dyspnea will establish medical necessity for the exercise test and spirometry. Attach modifier 59 to 94010 to indicate it was a separate and distinct test from the exercise test. (Spirometry is normally bundled into 94620, but your physician performed the exercise test to diagnose exercise-induced bronchospasm, thus creating the need for modifier 59.)

Extra modifier: If your physician orders testing in a facility-based lab or in his private office but does not own the PFT equipment, you should append modifier 26 (Professional component) to both 94010 and 94620-59 for your physician's interpretation of the test results. You can only report these codes without modifier 26 if your pulmonologist provides testing in his private office and owns the equipment and interprets the results.