Pulmonology Coding Alert

Question: One of our patients has unstable bronchospasms due to emphysema and therefore performs at-home spirometry once a month. The data is transmitted to our pulmonologist and he evaluates her condition. This was not a problem with the patient’s previous insurer, but she recently switched to Aetna and they’ve been denying the charges for 94016 even though we never bill it more often than every 30 days and we don’t bill for the education or transmission since we only review the report and write an interpretation. Can you advise?

Codify Subscriber

Answer: Although it appears that you’re appropriately reporting 94016 (Patient-initiated spirometric recording per 30-day period of time; review and interpretation only by a physician or other qualified health care professional), the issue probably lies in one factor you didn’t mention — your ICD-10 code. Although you didn’t specifically say what you reported, chances are strong that you billed it with an emphysema or bronchospasm diagnosis code, and Aetna does not typically consider those payable.

Aetna’s policy entitled “Home/Ambulatory Spirometry,” which the payer most recently updated on Aug. 30, 2016, specifically states, “Aetna considers home spirometry and telespirometry medically necessary for lung transplant recipients.”

The payer goes on to state that it considers this service “experimental and investigational for all other indications (asthma, idiopathic pulmonary fibrosis,  and persons with other chronic pulmonary diseases/disorders [e.g., emphysema]) because there is inadequate evidence that it will improve the care of persons with these disorders.”

Therefore, the only diagnosis codes that Aetna covers for this service are those in the T86.810-T86.819 range (Complications of lung transplant) as well as Z94.2 (Lung transplant status).

Your pulmonologist would certainly be within his rights to send an appeal letter to Aetna’s medical director explaining the utility of the remote spirometry for the patient’s emphysema-driven bronchospasms, but there is no guarantee that the letter would prompt a change in reimbursement. Your best bet is to either have the patient present to your office for the spirometry or to have the patient sign an advance beneficiary notice if she is only willing to perform telespirometry and therefore agrees to pay out-of-pocket for the approximately $25 charge each month.