Part B Insider (Multispecialty) Coding Alert

Published on Mon Feb 16, 2004 PDF

Pay attention to NCCI edits, common sense

Billing for pulmonary function tests, also known as spirometry, can be a minefield.

There are about 20 codes describing PFTs in the pulmonary section of the CPT book. "Some of these codes' descriptors make it clear that one code is distinct from others in the section, while other codes are ambiguous," says Jean Acevedo with Acevedo Consulting in Delray Beach, Fla.

If you follow the CPT book and your physician's documentation in coding for a claim, you may find yourself accused of unbundling. 

It's difficult to receive payment for PFTs separate from evaluation and management claims, says Judy Richardson, senior consultant with Hill & Associates in Wilmington, N.C. If the physician examines the patient, and then the patient returns at a later date for the PFTs, the PFTs are all you bill for on that date.

If the physician is in attendance for a pulmonary function study and "obtains a limited history, and performs a limited examination" that relates specifically to the PFTs, you shouldn't bill for a separate E/M service, Acevedo says. "This limited evaluation is part of the preprocedure work."

But if the physician does significant work in addition to what the PFT requires, you can bill a separate E/M service using modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), Acevedo adds.

She cites the example of a patient with a "new and persistent cough" who comes to see the physician. The physician may do "a detailed history and exam and, as part of his medical decision-making, determine that pulmonary function testing is recommended." In this case, the physician can bill for the PFTs separately.

If the physician sees the patient and performs PFTs during the course of the visit, the severity of the patient's condition and the extra work the physician performs would probably support billing a higher-level E/M service, Richardson adds.

The National Correct Coding Initiative edits are essential in figuring out which PFTs you can't bill separately, Acevedo says. For example, be aware that column 1 code 94060 (Bronchospasm evaluation ...) has 94200 (Maximum breathing capacity) listed in column 2.