Pulmonology Coding Alert

You can get paid separately for methacholine challenge tests (94070) and spirometries (94010) conducted on the same patient, but the tests must take place on separate encounters, and the challenge is providing supporting documentation.

Same Day vs. Different Day

Debra Anderson, a 13-year coding consultant with Salem Pulmonary Associates in Salem, Ore., says the encounters can take place on the same day as long as the documentation shows they were done separately. She states that spirometry can be billed if it is administered during separate encounters with the same patient. Its appropriate to bill for a spirometry done the day before or on the morning before an afternoon methacholine test is done.

But John S. Burns, RMC, a coder with the Medical Management Institute, a medical practice consulting firm in Alpharetta, Ga., says the Correct Coding Initiative (CCI) guidelines issued by the Health Care Financing Administration state that spirometry (94010, spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation) is included in the codes for methacholine challenge tests. Spirometry is always bundled into 94070 (prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics) and should never be coded separately, says Burns. He notes that an exception to this would be if the spirometry is done on a different day.

Adding Modifier -59 with Proper Documentation for Time

Anderson advises adding modifier -59 to the spirometry. The CPT states that modifier -59 is a distinct procedural service: For use when one procedure was distinct or independent from other services performed on the same day.

This lets the insurance company know theres something going on [with the patient]that this spirometry was done separate from the methacholine challenge, she explains. Carriers will request chart notes to determine why you performed a spirometry and then a methacholine challenge, adds Anderson, citing another reason for adding the -59 modifier to your spirometry.

Its critical to document your time, she adds. Say you did a spirometry in the morning, at 9:10 a.m. for dyspnea. If the patient returned that afternoon and ended up with a methacholine challenge because she was having exacerbation of her congestive obstructive pulmonary disease, you need to record the time the challenge was administered. You show the two different times and add -59 because the modifier is definitely contingent on a time factor.

Note: Burns adds that allergy tests (95070, inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds) can only be billed and reported on the same day as 94010 if the services are performed distinctly of each other. If both services are performed at different sessions of the day, says Burns, they can be reported. The modifier -59 should be used to indicate this distinction.

Understanding Methacholine Challenge Tests

Pulmonologists generally use methacholine challenge tests to indicate the presence of hyperactive airways, atypical presentation of asthma and occupational asthma. Patients who have normal pulmonary function at rest usually present with cough, dyspnea, wheezing or chest lightness. They have not responded to therapeutic trials of bronchodilators. Methacholine challenge tests may be used to monitor environmental control of bronchospastic inciting agents or response to therapy in suspected asthma cases.

Methacholine tests are diagnostic sensitive, explains Anderson. For example, she says if she codes a methacholine test with ICD-9 code 516.3 (interstitial lung disease), carriers want her to chart notes from the procedure. But if she codes the procedure with 786.09, (dyspnea, other) she says the carriers accept it.

This is because according to HCPCS, methacholine challenge tests are allowed by the following ICD-9 item/service codes:

493.00, 493.10, 493.20, 493.90, asthma (suspected)

786.00-786.09, respiratory abnormality such as
dyspnea, tachypnea, hyperventilation,wheezing and
shortness of breath unrelieved by bronchodilator

786.2, cough

Anderson says 94070 must be performed by a physician. Multiple spirometric determinations cannot be billed, Anderson notes, because they will be considered bundled with the 94070 procedure.

Lorraine Leonardo, billing manager with Allergy & Pulmonary Associates in Trenton, N.J., explains her office bills for the methacholine test [separately], then we bill for a simple spirometry, such as flow volume loops (94010). But, Leonardo cautions, more often than not private carriers will bundle a simple spirometry, such as a flow loop volume with the methacholine challenge test.

Whether the 94010 is kicked out depends on the carrier, says Leonardo. Leonardos office will also bill for the full spirometry, 94060 (bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]), which Leonardo says is conducted because you do have to have one with the post-study.