Pulmonology Coding Alert

Medicare and other payers typically specify additional guidelines, coverage limitations and bundling edits for 94010-94060. For example, Cahaba GBA's LMRP covering pulmonary function testing in Georgia which is typical of LMRPs nationwide specifies, "Alternative methods of reporting identical data which are duplicative of each other, or are included in another test, should not be billed separately."

Therefore, if the spirometry results are normal without bronchodilators, the carrier will consider further testing using 94060 unnecessary and subject to denial, says Cynthia Thompson, CPC, senior consultant at Gates, Moore & Co., a physician practice management and consulting firm in Atlanta. And because 94060 includes spirometry as described by 94010, it will be denied as bundled when billed at the same time as 94060. Likewise, 94060 should not be billed at the same time as 94070, Thompson says.

Carriers will likely deny 94375 an alternative method of calculating a standard spirometric parameter if you bill it on the same day as spirometry (94010-94070). Also, payers will not separately reimburse individual test codes 94150 (Vital capacity, total [separate procedure]) and 94200 (Maximum breathing capacity, maximal voluntary ventilation) when reported with the more comprehensive 94010, 94060 and 94070, which include graphic record, total and timed vital capacity, expiratory flow rate measurements and maximal voluntary ventilation.

Because 94070 describes a more extensive procedure than standard spirometry, the medical record must substantiate the need for additional, repeated spirometric studies over a long time. For example, during a methacholine test, the pulmonologist performs multiple spirometries to determine if the patient has asthma, says Teresa Thompson, CPC, a pulmonology coding and reimbursement specialist in Sequim, Wash. The test includes multiple determinations. Therefore, you may bill only one unit of service.

Frequency limitations also apply. For example, as with 94070, when the assessment requires multiple tests on the same day, you may report only one unit of 94010-94060 or 94375, i.e., you may not bill multiple units of the same code on the same day.

Generally, carriers consider repeat testing reasonable and necessary "only if the results have the potential to affect treatment or improve patient compliance to a recommended regimen," according to Cahaba GBA's LMRP. Examples of medical justification include an unexpected change in respiratory disease symptoms or the need to evaluate the efficacy of ongoing therapy and/or to determine if a change in therapy is necessary. For example, Teresa Thompson says, repeat testing might be appropriate to determine if a nebulizer treatment has been effective or if the patient needs another treatment on the same day.

When reporting the codes for patient-initiated spirometric recordings (94014-94016), you should be cautious. Many carriers, including Cahaba GBA, consider these procedures medically necessary "only if the patient's control of bronchospasm is unstable (e.g., underlying chronic lung disease, changing environment) and is sufficiently severe as to require the patient to periodically and promptly adjust his or her regimen."

Prior to providing the services described by 94014-94016 (or any repeat spirometric testing that may be denied by Medicare as not reasonable and necessary), the physician may ask that the patient sign an advance beneficiary notice (ABN) to acknowledge that if Medicare denies reimbursement for services rendered, he or she is responsible for payment. When submitting the claim to Medicare, attach modifier -GA (Waiver of liability statement on file) to the appropriate CPT code to indicate to the carrier that you have obtained a signed ABN from the patient.

Despite previous CCI edits, CMS has stated that pulmonary medicine codes are not bundled into the E/M codes. Therefore, if the pulmonologist performs a history and physical examination on the same day as the testing, you may bill the appropriate-level E/M service in addition to the PFT, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. The physician service provided, however, must exceed the level of E/M inherent in the test performance. To show the separate nature of the E/M service, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the applicable E/M code, and the medical record must support billing for the additional service.

For example, a patient arrives for a previously scheduled spirometry and complains of a rash that has recently appeared on his right arm. If the pulmonary physician performs a separate history and examination because of the new complaint, he or she may bill the appropriate E/M service (e.g., 9921x, Office or other outpatient visit for the evaluation and management of an established patient ) appended with modifier -25 in addition to the spirometry (94010).