Pulmonology Coding Alert

Your practice performs so many pulmonary function tests (PFTs) that you probably think you have spirometry coding down pat. But the truth is many coders still have questions about reporting these common procedures. Avoid denials or lowered reimbursement by reviewing these spirometry ins and outs.

Use 2 Codes for New Patient Testing

Upon their first visit, all new patients with respiratory symptoms get a baseline spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation), shares Suzanne Wood, CPC, with the Pulmonary Associates Medical Group in La Mesa, Calif. When the pulmonary function technologist performs this test, normal procedure is to print the graph of the spirometric tracing, print the values for vital capacity, forced vital capacity, and flows, and put that information in the chart after the pulmonologist interprets the results.

At the first visit, the practice reports spirometry along with the appropriate E/M code for a new patient (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) or consult (99241-99245, Office consultation for a new or established patient ...), says Wood. No modifier is needed on the E/M code, unless the payer requires it.

Going forward, established patients are tested with spirometry whenever their symptoms or complaints warrant it and the pulmonologist feels it is necessary, Wood adds. Hone in on Global/Modifier Billing With POS Setting can clue you in to when to break out 94010's professional and technical components.

"We have a spirometer in our office that we use to perform simple spirometry," Wood explains. Because Pulmonary Associates Medical Group is in a private office setting (place of service 11) and the practice owns the machine, employs the technician, and the physician does the interpretation, "we code 94010 without any modifiers," Wood says.

Don't miss: In facility-based locations (for instance, place of service 22), switch from the global code to a modifier-appended code. One of the pulmonologists with the Pulmonary Associates Medical Group interprets spirometries that patients receive at a local hospital. "Because the hospital bears the cost of the equipment and physical space, I append modifier 26 (Professional component) to the appropriate CPT pulmonary function codes" Wood says. The hospital appends modifier TC (Technical component) to the same codes and submits a separate bill.

Don't let 94060 bundling conventions lead you astray.

Code 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) may be considered a component of the six-minute walk (94620, Pulmonary stress testing; simple [e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry). You can use modifier 59 (Distinct procedural service), however, to break this bundle if the pulmonologist performs and clearly documents a medically necessary separately identifiable service, according to a 2009 University of California Davis Health System PFT compliance notice (see www.ucdmc.ucdavis.edu/compliance/pdf/pulmfunctiontests.pdf).

Support the spirometry as separate with these facts:

1. Separate measurements: These two tests -- 94060 and 94620 -- essentially measure completely different things, which can help you separately identify them, says Jill M. Young, CPC, CEDC, CIMC, of Young Medical Consulting in East Lansing, Mich. Bronchodilation responsiveness includes spirometry, which measures the patient's vital capacity and pulmonary flows (FEV1, FEF 25 percent-75 percent, etc.) before and after bronchodilator administration. The six-minute walk measures how a patient fares during exercise and the distance he is able to achieve, she observes.

A physician commonly orders a six-minute walk to decide whether to prescribe oxygen, adds Donna Ferreira, CPC, of Pulmonary Care, PC in Fall River, Mass. Conditions that may require this type of test include chronic obstructive pulmonary disease (COPD, 491.21), emphysema (492.8), or pulmonary hypertension (416.0).

2. Different reasons: A patient may require the two tests for separate reasons in order to determine diagnosis, monitoring, and treatment options. For instance, if the pulmonologist performs a PFT to monitor how the patient's disease is progressing -- for example, decreasing lung volume -- she may additionally order a six-minute walk to evaluate whether the patient can walk farther on the current treatment regimen, Young says. In this case, you would append 59 to the bundled service: 94060.

3. Involved Areas: You can also differentiate

spirometry and the six-minute walk by looking at studied anatomy. A PFT involving spirometry measures lung volume (vital capacity and/or forced vital capacity) and flow. A physician uses 94620 to determine the patient's exercise capabilities, which involve the lungs, heart, muscles, and circulation, adds Becky Zellmer, CPC, MBS, CBCS, medical billing and coding supervisor for SVA Healthcare in Milwaukee. Also, 94620 does not include a bronchodilator response, which is a feature of 94060.

Example: A patient performs a six-minute walk (94620) and the pulmonologist determines that the problem is with the lungs. She then decides to order a bronchodilation responsiveness study to see if the patient's respiratory status improves after bronchodilation, explains Zellmer. In this case, you would also append 59 to 94060.

You cannot, however, unbundle a service you typically also provide with spirometry. While every patient may also  receive pulse oximetry readings (94761, Noninvasive earor pulse oximetry for oxygen saturation; multiple determinations [e.g., during exercise]), pulse oximetry is not separately payable as it is bundled into any other payable service performed on the same day, in this case the E/M service (99201-99205 or 99241-99245), explains Wood. Oximetry results, however, are an important way to document medical necessity for oxygen therapy, notes Wood. They help guide adjustments to the oxygen liter flow for patients at rest or participating in exercise.