Pulmonology Coding Alert

5 easy steps to proper coding

When your pulmonologist administers a methacholine challenge test (95070) to treat a patient's respiratory problem, you need to know how to properly code multiple spirometries and attach the correct modifiers for your physician's work. Follow the expert advice below, and you'll find methacholine testing not as challenging as you may think.

1. Report Professional and Technical Components

Use 95070 (Inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds) for the methacholine administration, says Sharon Tucker, CPC, president of Seminars Plus in Fountain Valley, Calif.

This code does not include payment for the pulmonary function tests (PFTs) required to evaluate the patient's prolonged postexposure bronchospasm, so you should report 94070 (Prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics) for the postexposure bronchospasm evaluation in addition to 95070.

Pulmonologists use methacholine provocation challenge tests (95070) to determine if a patient has respiratory diseases such as bronchial asthma (493.9x). Physicians perform spirometries after each methacholine inhalation to measure the patient's airway responsiveness and to determine if the patient exhibits a bronchospastic response (519.1).   

Typically, physicians perform methacholine studies in a hospital's pulmonary function testing lab. When this occurs, each "entity" reports its portion of the service. In other words, the pulmonary function lab will report the methacholine administration (95070) in addition to the evaluation's "technical" portion. That is, the lab will list 94070-TC for the spirometric measurements. Your physician will report his or her "professional" portion, which includes interpreting the spirometric measurements (94070-26), says Kelley L. Emig, LPN, CPC, CHCC, a coding specialist with Coding and Reimbursement Solutions Inc., in Port St. Lucie, Fla.

Remember that you can report 94070 only once, not for each unit of service, Tucker says. For instance, if your physician performs multiple spirometries, you cannot report 94070 or 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for each test.

2. Check the Report for Appropriate FEV1 Drop

Methacholine testing measures patients' levels of forced expiratory volume in one second (FEV1). So you should watch for these measurements in the report to support medical necessity for the tests, coding experts say.

For instance, your pulmonologist may examine an established patient (99211-99215) for shortness of breath (786.05) and evaluate the patient's labored breathing. As part of the evaluation, your physician performs a spirometry (94010) to measure the patient's respiratory function, which is near normal. 

The patient's symptoms lead your pulmonologist to suspect asthma (493.xx), so he or she orders a methacholine challenge test in the PFT lab. The patient receives the methacholine in the lab, followed by another spirogram to measure the reaction to the methacholine. The patient then receives increasing doses of methacholine, with additional spirometric readings, to evaluate his or her response to escalating concentrations of methacholine. 

The physician must prepare a written report of the test, including the interpretation of the findings. For example, the patient's record indicates a 20 percent drop in FEV1. Upon examination, the patient exhibits audible wheezing after the second dose of methacholine, which indicates airway hyper-responsiveness.

"We do a spirometry after each dose of methacholine," says Rona Hamill, a billing specialist at Asthma and Allergy Center in Papillion, Neb. "We are looking for a patient's FEV1 to drop 20 percent. So that could involve as many as six spirometric readings, depending on how the patient responds."

3. Discern Between Pre- and Post-Test Readings

When your physician performs a baseline spirometric reading (94010) after methacholine administration, 94070 includes that reading, and you cannot report it as a separate procedure, says Teresa Thompson, CPC, CCC, a coding and reimbursement specialist in Sequim, Wash. Also, remember that you cannot bill subsequent spirometric determinations because CPT bundles them into 94070, she says. 

Sometimes, however, your pulmonologist may perform the spirogram before the methacholine test to check for bronchospasm (519.x).

When this occurs, you may report the initial spirometry (94010) in addition to the methacholine challenge (94070), coding experts say. The CPT description only specifies an inclusion for "subsequent spirometrics," so CPT doesn't include the initial spirometry in the prolonged postexposure evaluation.

Append modifier -59 (Distinct procedural service) to the spirometry code to identify it as a separately distinct and billable service, Tucker says. The modifier indicates to the insurance carrier that the methacholine challenge test and the spirometries are distinct and separate services.

For example, if your physician has a patient with shortness of breath (786.05) and the physician performs a spirogram (94010) on the same day prior to the methacholine challenge, you can bill the spirometry with modifier -59.

4. Append Modifier -59 for Bronchodilator Use

When a patient's spirogram comes out normal, your pulmonologist may order a methacholine test to elicit a bronchospasm. So you should know how to report treatment for the bronchospasm. Often, the physician will administer bronchodilation (94640) to reverse the bronchospasm. Your physician should document this service separately from the methacholine challenge, Thompson says.

The National Correct Coding Initiative (NCCI) bundles the administration of the bronchodilator for acute airway obstruction (94640) into the prolonged post-exposure evaluation (94070).

If the methacholine testing intentionally causes the acute airway obstruction, the reversal of this induced effect should occur as an integral part of the prolonged postexposure evaluation. An exception occurs when the physician administers bronchodilation for a separate and distinct reason, such as during a separate session or earlier in the visit. In this case, you should append modifier -59 to 94640. Because NCCI doesn't bundle 94640 into 95070, reporting these two services together may seem reasonable. Even so, you should ask individual carriers for clarification before using both 94640 and 95070.

5. Use Modifier -25 for E/M Visits That Include Tests

You should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service (99201-99215) a physician performs with methacholine challenge tests. This indicates to payers that the patient's condition requires a separately identifiable and billable E/M service.

For instance, a patient presents with shortness of breath (786.05). Your pulmonologist evaluates the patient and decides that a spirometric measurement may indicate whether the patient has pulmonary dysfunction.  

The spirometry does not indicate any abnormality, but based on the patient's history of present illness and family history of pulmonary disease, your physician suspects reactive airway disease and decides to perform a methacholine challenge.  

You can report your pulmonologist's evaluation of the patient's condition separately from the testing. Report the E/M service by appending modifier -25 to the appropriate code (9920x-25). 

But ask your local carrier about using modifier -25 to report E/M services with 94070 and 95070 because not all carriers require it when billing for E/M services with methacholine tests. 

If your practice schedules the patient to come in for a methacholine challenge, you cannot bill an E/M code, Thompson says.