EM Coding Alert

As a pulmonology coder, evaluation and management (E/M) visits are a staple of your workflow. But how familiar are you with reporting these visits when the pulmonologist also performs spirometry during the encounter?

See if your knowledge matches the answers to the five questions below.

Question 1: An established patient presents for a follow-up E/M visit to assess their chronic obstructive pulmonary disease (COPD). The pulmonologist orders a simple spirometry test to examine the efficacy of the patient’s current medication. After reviewing the results, the pulmonologist adjusts the medication dose and tells the patient to return in six months. How do you report the E/M visit with simple spirometry test during the encounter?

Question 2: A new patient presents to a pulmonologist for pulmonary evaluation including pulmonary function testing (PFT). After capturing a history and physical examination, the pulmonologist performs simple spirometry on the patient. They make and complete three attempts. However, the values are inconclusive for the pulmonologist to make a definitive diagnosis. What procedure code(s) will you assign for this encounter?

Question 3: A new patient presents to a pulmonologist after experiencing a bronchospasm during basketball practice the day before. The pulmonologist performs a spirometry test with pulse oximetry and electrocardiographic recordings before and after having the patient run on a treadmill for 20 minutes. After reviewing the results, the pulmonologist diagnoses the patient with exercise-induced bronchospasm and prescribes them an inhaler. What CPT® code(s) will you assign for the encounter?

Question 4: An established patient recently underwent a lung transplant, and the pulmonologist ordered patient-initiated spirometric recording for 30 days following the procedure. The provider set up the equipment and instructed the patient on how to use the device every day. At the end of the 30 days, the pulmonologist reviewed and interpreted the data and performed a 30-minute video visit with the patient to review the results and discuss the management plan. How do you report the services provided?

Question 5: During an E/M visit with an established patient, the pulmonologist only assesses the total vital capacity of the patient’s lungs. How do you report this service?

Compare your work to the answers.