Pulmonology Coding Alert

Pulmonologists and allergists often use methacholine (J7699) provocation challenge) tests (94070) to determine if a patient suffers from respiratory diseases such as asthma (493.xx). These tests indicate if a patient has airway hyper-responsiveness, which is characteristic of bronchial asthma (491.2x). Spirometries (94010) are performed after each methacholine inhalation to measure the patient's airway responsiveness and to determine if the patient exhibits a bronchospastic response (519.1x). Proper reimbursement for methacholine provocation and the accompanying spirometry requires adequate documentation and knowledge of what can be coded. Which CPT Codes Apply and Who Can Bill Them Two different codes apply to methacholine challenge testing, which can be used at the same time.

Code 94070 (Prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics) can be divided into a technical and professional component. For example, if the physician supervises and interprets the test in a hospital pulmonary function testing lab (PFT), he or she bills the professional component or interpretation with 94070 and appends modifier -26 (Professional component). The professional component (94070) may occur during an office visit, and then the lab or hospital bills the technical component by appending modifier -TC (Technical component) to 94070 if the lab administered the test. If the professional and technical components were performed by the physician's office, both can be billed by the physician reporting 94070 with no modifier.

Code 95070 (Inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds) cannot be divided into technical and professional components. It is for the administration of the methacholine in the inhalation bronchial challenge test. Whoever administers the drug bills for it. If the administration occurs in a hospital setting, the hospital bills for the administration of the methacholine (95070). If the administration is performed in the physician's outpatient office or lab, then the physician bills for it. In addition, whoever administers the test and methacholine also can bill for the methacholine (J7699). A Typical Scenario An established patient presents with shortness of breath (786.05). A pulmonologist examines the patient (99211-99215) and appends 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 appropriate E/M code. An evaluation of the patient's labored breathing is done. A spirometry (94010) is performed to measure the patient's respiratory function, which is near normal. The patient's symptoms lead the pulmonologist to suspect a possible asthmatic condition (493.00, 493.10, 493.20, 493.90), so a methacholine challenge test is ordered. The methacholine is administered in the doctor's office, with the time of the administration noted in the patient's record. To measure the patient's [...]