Pulmonology Coding Alert

Medicare will pay you twice as much for billing global code 94014 starting in July. But that's if you know how to prove medical necessity for at-home oxygen testing a more difficult task than you might think.
 
Because of inconsistencies in the 2003 Medicare Physician Fee Schedule database, Medicare will increase payment for 94014 and 94015, according to CMS memorandum AB-03-070. Payment for the codes will vary based on locality, so check with your local carrier. On average, Medicare will now pay $55.14 for 94014 (Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration and physician review and interpretation), up from $36.02. In addition, CMS is raising the reimbursement for 94015 (... recording [includes hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic recalibration]) to $29.77 from $10.66. CMS didn't increase rates for 94016 (...  physician review and interpretation only).
 
Keep in mind that some carriers, such as HGSAdministrators in Camp Hill and Williamsport, Pa., reimburse only for 94014 and will not allow either 94015 or 94016 to be billed, says Carol Pohlig, BSN, CPC, RN, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Use 94014 for Extreme Cases At-home spirometry is not intended for the average asthmatic, Pohlig says.
 
A pulmonologist performs home-based spirometry as a surveillance method to prevent acute situations in patients with chronic asthma (493.xx) or intercurrent upper respiratory infections (465.9) or following lung transplants (V42.6), Pohlig says. The patient must have been hospitalized twice or visited the emergency room three times in the past 90 days. "In order for home spirometry to be medically necessary, the patient's condition is quite unstable," she adds.
 
Your pulmonologist must meet several requirements from which he or she can select secondary diagnoses (asthma or lung transplant status should be listed first):
   The patient must have severe asthma with dyspnea (786.00, Dyspnea; respiratory abnormality, unspecified) at rest.
   Forced expiratory volume in the first second (FEV-1) of less than 40 percent, predicted after bronchodilator administration (measured 14 days before or after emergency department visit or hospitalization).
   Evidence of end-stage disease by any one of the following: hypoxemia (799.0) at rest, secondary polycythemia (289.0), or cor pulmonale (416.9)/right heart failure (428.0) determined by electrocardiogram, echocardiogram or cardiac catheter.
 
If the patient is not an asthmatic with the above conditions, codes in the 94014-94016 range would be considered medically necessary only for a lung transplant patient, Pohlig adds. Submit Bills Consistently to Avoid Denials Higher reimbursement rates for 94014 may mean pulmonologists will use at-home monitoring more frequently than in the past.
 
Before the payment increase, most physicians didn't use 94014, says Charlie [...]