Pulmonology Coding Alert

Question: A new patient visited a pulmonology practice after experiencing shortness of breath while working out. The physician ordered an exercise test with electrocardiographic recordings as well as pulse oximetry and spirometry before and after the exercise test. The patient did experience a mild exacerbation of their condition, which was treated with a metered dose inhaler (MDI). The pulmonologist diagnosed the patient with exercise-induced bronchospasm, prescribed an MDI, and requested a follow-up appointment in two months.

What codes should I assign?

South Dakota Subscriber

Answer: In this case, you’ll assign 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.) to report the evaluation and management (E/M) visit. The patient presented with an undiagnosed new problem with uncertain prognosis and the physician prescribed medication after diagnosing the patient with exercise-induced bronchospasm. These two factors meet the requirements for a moderate level of medical decision making (MDM).

Next, you’ll assign 94617 (Exercise test for bronchospasm, including pre- and post-spirometry and pulse oximetry; with electrocardiographic recording(s)) to report the pulmonary exercise test. You’ll also need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99204 to show that the exercise test was separate from the E/M visit.

Lastly, you’ll turn to the ICD-10-CM code set to locate J45.990 (Exercise induced bronchospasm) for the provider’s diagnosis. If the physician is unable to arrive at a formal diagnosis, you’ll assign R06.02 (Shortness of breath) as the reason for the visit and the testing.