Pulmonology Coding Alert

Question: Can you bill ‘94620’ along with a full PFT, codes ‘94060’, ‘94726’ and ‘94729’? It is an interpretation only so a 26 modifier is used. The diagnosis used by the physician was the same for all testing. We were told in a seminar that we could use a 59 modifier to get everything paid but they are still being denied by Medicare. Should a different modifier be used?

Missouri Subscriber

Answer: When your pulmonologist performs pulmonary function tests, it is likely that some tests will be bundled with others and will not be paid out separately.

As per AMA instructions, +94729 (Diffusing capacity [e.g., carbon monoxide, membrane] [List separately in addition to code for primary procedure]) is an add-on code that can be reported with 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) or 94726. However, as per Correct Coding Initiative (CCI) Edits, 94060 is a column 2 code for 94620 (Pulmonary stress testing; simple [e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry]) with the modifier indicator ‘1’ which means that the coding bundle can be separated if a suitable modifier is used. To break the coding bundle, you will have to append the modifier 59 to 94060. But, in order to break the bundling, you will need to submit adequate documentation to show that both these services were medically necessary and were provided in the same session.

There is no CCI edits for the rest of the codes. You will only have to append the modifier 59 (Distinct procedural service)to 94060. The rest of the codes can be submitted without the use of any modifiers (apart from the modifier 26 as this is only an interpretation). Make sure that you are providing all the necessary documentation.  The need to perform each test should be well illustrated in the documentation.  Otherwise, the payer will question legitimacy to perform each procedure. If you still are getting a denial, check the reason for the denial.