Pediatric Coding Alert

You’ll be breathing a sigh of relief if you remember these 3 things.

Pulmonary testing can be a coding nightmare if you aren’t familiar with the different tests and what you can, and cannot, code separately. To keep them all straight, you need a thorough mastery of CPT^® guidelines and National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits.

But don’t worry. We’ve distilled all that information into three handy nuggets of information that you can use the next time your pediatrician tests a patient to determine whether the patient has a lung condition and, if so, what medication will be effective in treating it.

1. Remember CPT^®, NCCI Bundles for Spirometry

The first thing to remember about pulmonary testing codes is the way some smaller, specialized tests bundle into larger, more comprehensive testing services. “Codes 94150 [Vital capacity, total (separate procedure)], 94200 [Maximum breathing capacity, maximal voluntary ventilation], and 94375 [Respiratory flow volume loop] have a parenthetical statement that instructs you not to report them in conjunction 94010 [Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation],” says JoAnne M. Wolf, RHIT, CPC, CEMC, AAPC Fellow, coding manager at Children’s Health Network in Minneapolis, reminds coders.

That’s because the services described by 94150 and 94200, for example, are component parts of 94010 as the latter service’s descriptor notes.

You’ll find a similar situation when you look at the NCCI PTP edits involving 94010. Here, “94150, 94200, and 94375 are bundled into 94010,” Wolf notes. In other words, when your provider performs a comprehensive service, or column 1 code, component procedures of that service, or column 2 codes, either cannot be reimbursed separately (modifier indicator 0) or can be reimbursed separately providing an NCCI-approved modifier is appended to the column 1 code and/or the column 2 code (modifier indicator 1).

For the pulmonary testing codes, the bundling looks like this:

Coding Alert 1: Even though “codes 94150 and 94200 do have a 1 listed in the modifier indicator column, indicating that use of a modifier may be appropriate, you can only append a modifier such as modifier 59 [Distinct procedural service] if your provider performed the lung capacity/ volume measurement in a separate encounter. If performed together, then the billing and use of the modifier would not be appropriate,” Wolf cautions.

Code 94375, however, has a 0 in the modifier column, “indicating that a modifier would never be considered appropriate,” and the services cannot be unbundled under any circumstance, Wolf clarifies.

2. Understand How Spirometry Bundles Into Bronchodilation, Bronchoprovocation

Spirometry itself is also bundled into two common respiratory tests: 94070 (Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents [eg, antigen[s], cold air, methacholine]), which is used to diagnose a lung condition such as asthma and involves the patient inhaling a chemical such as methacholine to restrict the airways and induce a bronchospasm, and 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration), which is used to test the effectiveness of bronchodilator drugs such as Albuterol in treating asthma and involves the patient inhaling the drug, which widens the airways to make it easier for the patient to breathe.

In both tests, your pediatrician will use spirometry before and after administering the drugs to determine how the drugs affect the patient’s lung capacity. Unsurprisingly, then, as spirometry is a component of both bronchoprovocation and bronchodilation, 94150, 94200, and 94375 all bundle into 94060 and 94070 in the same way as they bundle into 94010.

Coding Alert 2: Spirometry itself bundles into 94060 and 94070, though the modifier indicator of 1 means you can use modifier 59 to bill for both services. But, as with 94150 and 94200 bundling into 94010, it would also not be appropriate to unbundle 94010 from 94060 or 94070 if the services are performed together. If your provider performed spirometry in a separate encounter, then you could go ahead and append modifier 59 to the 94010 to separate the services.