Pulmonology Coding Alert

Question: A patient recently visited us and enquired about the mandated spirometry tests required for a new insulin inhalation treatment. How should we report these tests? 

Washington Subscriber

Answer: There is indeed an inhaled insulin now available by prescription, a new medication AFREZZA^®.  The labeling for AFREZZA^® mandates spirometry testing (specifically FEV1) to rule out chronic lung disease prior to initiating therapy, six months after initiation and every year thereafter.

According to American Thoracic Society (ATS) recommendations, you can use the following guidelines:

• For spirometry before initiation of the treatment: You can report the test with 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) and attach ICD-9 codes V72.85 (Other specified examination) and an additional code such as 250.xx (Diabetes mellitus) as an additional diagnosis for the underlying diabetic condition. 

• For spirometry after first 6 months of therapy: You can report the spirometry test with 94010 and attach V58.83 (Encounter for therapeutic drug monitoring), V58.67 (Long term [current] use of insulin), and an additional code such as 250.xx for underlying condition (diabetes) as additional diagnosis. 

• For annual spirometry testing: You can report the annual spirometry test with 94010 and attach V58.83, V58.67, and an additional code such as 250.xx for underlying condition (diabetes) as additional diagnosis.

Under ICD-10, the recommended diagnostic codes will cross over to the following:

• V72.85 ­will become Z01.89 (Encounter for other specified special examinations)

• 250.xx will become E10.--- (Type 1 diabetes mellitus…) or E11.--- (Type 2 diabetes mellitus…)

• V58.83 will become Z51.81 (Encounter for therapeutic drug level monitoring)

• V58.67 will become Z79.4 (Long term [current] use of insulin).

ATS also suggests that it may be appropriate to append modifier 32 (Mandated services) with the code indicating that the test is “mandated” by the FDA as part of the labeling restrictions for inhaled insulin.