Pulmonology Coding Alert

Question: I have an established patient who came in for a follow-up visit after an episode of respiratory distress with wheezing. The pulmonologist initially prescribed a nebulizer and inhaler treatment. During the follow-up visit, the physician evaluated the patient’s condition, performed a spirometry test, and discussed further management. The doctor then treated the patient with an inhaled bronchodilator and conducted a subsequent spirometry test to determine if the bronchodilator changed their breathing and decide if the patient has asthma.

Can I use code 94010 to report the visit?

Maryland Subscriber

Answer: While code 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation) covers the spirometry tests, 94060 is a better choice as it covers the bronchodilation.

In your situation, 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) is the correct choice because it includes both spirometry tests (before and after the bronchodilation) as well as the bronchodilation. You will also report the appropriate evaluation and management (E/M) code in the 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, …) code set, appended with modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) because the modifier is required when a procedure is provided during an E/M visit.