Pulmonology Coding Alert

Look out for incompatible code pairings to avoid denials.

If you think you know everything there is to know about reporting Pulmonary Function Tests (PFTs) then you could be setting yourself up for a headache. One wrong inclusion or exclusion, and your payment will go out the window.

Definition: PFTs measure the ability of the lungs to use air. The results help diagnose breathing problems. PFT is collective descriptor used for the following pulmonary diagnostic testing procedures: Spirometry, lung volume, diffusion capacity, lung compliance, residual volume measurement and pulmonary studies during exercise testing.

Myth #1: You Won’t Report PFTs as Part of Other Procedures

Reality: You’ll find CPT® codes describingvarious PFTs included in the descriptors of other procedures, such as spirometry and bronchospasms evaluations. 

The most common codes you are most likely to encounter from your pulmonologist are:

• 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). Spirometry measures expiratory airflow and volumes and is the basic form of most pulmonary function testing.
• 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration). When spirometry is performed before and after the administration of a bronchodilator, you report 94060.

You have to bill PFTs with the appropriate CPT® code within the range 94010-94799.

Myth #2: PFT Codes Encompass All the Ancillary Procedures

Reality: Not always. Maximal breathing capacity, vital capacity and flow-volume loop are components of spirometry and, therefore, 94200(Maximum breathing capacity, maximal voluntary ventilation), 94150 (Vital capacity, total [separate procedure]) and 94375 (Respiratory flow volume loop)are not reported in conjunction with 94010 and 94060.You may be able toreport them if performed alone. Codes 94150 and 94200 may be reported on the same day, if performed separately for separate reason, and the information provided by these tests could not have been obtained through spirometry. Make certain your physician’s documentation specifies this. 

Note: Pulmonologists use the flow-volume loop to identify patterns of inspiratory and/or expiratory obstruction in central or peripheral airways. Again, you will report that with 94375, but it is bundled into spirometry and cannot be reported separately.

Myth #3: You Will Always Report a PFT Global Code

Reality: PFT codes contain both a professional and technical component, and you have to use modifiers 26 (Professional component) and TC (Technical component) to report the corresponding portions of your PFT code, such as 94010 or 94060. You report the appropriate code with a modifier appended to describe the pulmonologist’s portion of the rendered service when you are not billing for the entire service (which includes the technical and professional portions).

Professional component only: If the tests are performed in an outpatient facility where the pulmonologist does not employ the staff or own the equipment, you should report 94010 with modifier 26 appended to indicate the professional component.The facility bills 94010-TC.

Both components (the global service): If the tests are performed in an office setting, where the pulmonologist owns the equipment, you will report 94010 or 94060 without a modifier. The reason is the global coderelative value units (RVUs) include values for physician work, practice expense and malpractice expense, as explained by CMS.

Bill all other CPT® codes for the pulmonary function test individually. The general rule is to append modifier 26 if the services are carried out in a facility-based setting, and your physician has given a written interpretation and report.

Myth #4: Patient-Initiated PFTs Don’t Have Codes

Reality: You may encounter cases of patient-initiated spirometric recordings. There area set of codes available to report this service: 

• 94014 (Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration and review and interpretation by a physician or other qualified health care professional), 
• 94015 (…recording [includes hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic recalibration]) and 
• 94016 (Patient-initiated spirometric recording per 30-day period of time; review and interpretation only by a physician or other qualified health care professional).

Many payers accept these procedures as 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.”But others still deny this service completely because the clinical efficacy has not been established.

Caution: You report 94014 only once in a 30-day cycle as described by the code, even if your pulmonologist receives the spirometric data several times in a month. You may be denied your deserved dollars if you miscalculate and report 94014 twice in the 30-day period.

Tip: To make things easier on yourself, schedule your reporting of 94014 around the same date each month and be sure not to overlap the days to avoid denial. 

Myth #5: You Have No Other Procedures For Measuring Lung Volumes

Reality: You have several additional codes for lung volume measurement. Some other relevant PFTs for measurement of lung volumes are:

Plethysmography: Pulmonologists utilize this test to determine total lung capacity, residual volume, functional residual capacity, and airway resistance. You report the code 94726 (Plethysmography for determination of lung volumes and, when performed, airway resistance). 

Helium dilution or nitrogen washout: Pulmonologists perform gas dilution or washout for the determination of lung volumes. This is recommended in conditions like asthma, cystic fibrosis, etc. You report 94727 (Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes).

Impulse oscillometry: This is the test recommended in conditions like asthma, chronic obstructive pulmonary disease (COPD). Youmayreportthis in addition to gas dilution techniques with 94728 (Airway resistance by impulse oscillometry).

“All three codes (94728, 94010 and 94060) are bundled into spirometry, and you wouldn’t perform them separately on the same day. Codes 94726 and 94727 could be unbundled but only if medically necessary to obtain non-overlapping information,” says Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.