Pulmonology Coding Alert

Question: Recently, several insurance plans denied coverage for an office visit when reported with spirometry. In the first case, we reported 99215-25 for the office visit and 94060 for bronchospasm evaluation on the same day. In another case, the pulmonologist performed the bronchospasm evaluation (94060) two weeks prior to the office visit (99215). In both cases, the carriers denied coverage for the office visit and paid only for the bronchospasm evaluation. Am I failing to add a correct modifier or do you know of any documentation that can aid in the appeal?

California Subscriber

Answer: In both scenarios, the insurance company should pay for both the E/M-25 service (99215, Office or other outpatient visit for the evaluation and management of an established patient ....] [Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or  other service]) and the pulmonary function tests (94060, Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration).

You should appeal the insurance company payment decisions in both examples above. In the first example,  check with the insurance company to determine if it requires modifier 25 on the E/M service when reporting an accompanying PFT. Perhaps the 25 modifier triggered the denial if the company doesn't require it. In the second example, there is no justification for denial as the services were performed two weeks apart.