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Question: A 55-year-old patient presented to the pulmonologist with swollen ankles and difficulty breathing. The pulmonologist performed a complete pulmonary function test (PFT), which included spirometry, plethysmography, and diffusing capacity testing. The physician also ordered chest X-rays with posteroanterior (PA) and lateral views, which were captured in house. The PFT results showed decreased lung function, and the chest X-rays revealed fluid in the lungs. The pulmonologist diagnosed the patient with congestive heart failure (CHF) and prescribed diuretics and ACE inhibitors.

How do I report this visit?

Missouri Subscriber

Answer: Starting with the complete PFT, you’ll need three CPT^® codes to report the services provided. Use either 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation) or 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) depending on what the pulmonologist documented for the spirometric procedure. You’ll assign 94060 if the pulmonologist captures measurements before and after administering a bronchodilator. If the documentation doesn’t mention medicine being administered, then you will use 94010.

Next, you’ll assign 94726 (Plethysmography for determination of lung volumes and, when performed, airway resistance) to report the plethysmography service, which measures the amount of air the lungs can hold. You’ll then use add-on code +94729 (Diffusing capacity (eg, carbon monoxide, membrane) (List separately in addition to code for primary procedure)) for the diffusion capacity test.

The last procedure code you’ll need for this encounter is 71046 (Radiologic examination, chest; 2 views) to report the two-view chest X-ray.

You mentioned that the pulmonologist documented a CHF diagnosis, but the ICD-10-CM code book includes several options for heart failure diagnoses. For the information you provided, you’re best to assign I50.9 (Heart failure, unspecified), which includes a diagnosis of CHF not otherwise specified (NOS).

Mike Shaughnessy, BA, CPC, Development Editor, AAPC