Pulmonology Coding Alert

Question: When appending modifiers with E/M service during a pulmonary function test (PFT), I'm not sure which one to add to the pulmonary function code: modifier 25 or modifier 59? Please help.

Illinois Subscriber

Answer: These two modifiers can really get confusing, but all is not lost. Just focus on the main  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).

Explanation: According to CPT's very own clarification, you should use modifier 59 only to distinguish one procedure from another procedure. For example, if you bill for a six minute walk test and spirometry, you would add modifier 59 to the spirometry (code it as 94620, Pulmonary stress testing; simple [e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post- spirometry and oximetry], 94010-59) because of a CCI edit that includes spirometry as a component of the walk test. When you're billing a PFT and an E/M, modifier 25 is not a requirement. However, be careful as some third-party payers actually demand its inclusion. Typically, modifier 25 is used to indicate you have documentation that supports an E/M as a significant and separate service from the work involved in another service or procedure. For example, if the patient underwent bronchoscopy after the decision was made during a subsequent hospital visit performed on the same day, you would add modifier 25 to the subsequent hospital visit code (99232-25, Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity...; 31622, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure].

This indicates that the hospital visit was for a reason other than to explain the bronchoscopy procedure, or perform the required preprocedural H&P.