Advanced Search

Pulmonology Coding Alert

Pursue Payment for At-Home Asthma Monitoring

Published on Sat Dec 01, 2001

Computer-enabled devices capable of telephonic spirometry have been used for lung-transplant patients for up to 10 years for the daily evaluation of a patient's condition and to help prevent early rejection of the new lung. The medical necessity of this daily evaluation spurred treatment centers to rally for a set of codes (94014-94016) that would be billable, and payable by Medicare:

  • 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 physician review and interpretation
  • 94015 ... recording (includes hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic recalibration
  • 94016 ... physician review and interpretation only.

    • Even though there has been coverage for this type of professional evaluation since 1999, the field of reimbursement for telephonic spirometry is very narrow and specific.

    The Whys and Hows of Telephonic Spirometry

    At-home monitoring devices can provide a physician with life-critical information daily. The measurements show a physician how efficiently a patient can force air out of the lungs and lend important data to asthma management.
     
    Pulmonologists most commonly use spirometers to measure pulmonary lung function of forced vital capacity or total volume of air expired (FVC), forced expiratory volume in one second (FEV1) or forced expiratory flow (FEF). And they use peak-flow meters to analyze the peak expiratory flow rate (PEFR) of a patient (the fastest rate at which air can move through the airways during forced expiration).
     
    At a predetermined time each day, the patient records his or her pulmonary function, and the results are stored in a small computer that is part of a spirometer. The data are downloaded via modem from the spirometer's computer to a remote computer at the physician's office or medical center. The information is trended and analyzed as complete spirometric tracings to identify problems like rejection for a lung transplant (V42.6), respiratory function (asthma, 493-493.90) or bronchiolitis obliterans (996.84) following a lung transplant.

    Get Complete Trace Information

    The essential elements for all Medicare reimbursement of patient-initiated at-home asthma management are complete spirometric tracings, which are reimbursed by Medicare monthly, not daily. Tracings are comprehensive measurements of the patient's pulmonary function such as a spirogram or flow-volume loop, i.e., specific tests, not just single, random numbers. This service is paid by Medicare only if the telephonic transmission of spirometric tracings is present in a composite report that documents and interprets a patient's respiratory data during a 30-day period. These tracings must be analyzed and documented.
     
    The composite report generated by the physician must be maintained in the patient's record. This protects the physician and is required for an insurance-carrier audit.
     
    "Coders need to be sure that there is a written interpretation by the physician or technician that reviews tracings for that month, before submitting a bill to Medicare," says Walter J. O'Donohue, MD, FCCP, FACP, chairman of the CPT committee of the American College of Chest Physicians (ACCP) and a representative to the AMA CPT advisory committee for ACCP.

    How the Codes Break Down

    There are specific differences between 94014, 94015 and 94016 when billing for telephonic spirometry. A physician or respiratory facility/lab can never bill for all three. Also, because these codes are separate and specific for telephonic spirometry, no modifiers are needed.
     
    Code 94014 is billed when a pulmonologist provides the complete telephonic spirometry service, i.e., his or her office owns and maintains the equipment, takes in and monitors the patient data via the phone, and the physician interprets the information and writes a report. This is the all-inclusive code that describes the technical, professional and interpretative services.
     
    Code 94015 defines the technical aspect and is used by a facility that owns and maintains the spirometry equipment, and takes the spirometric tracings over the phone. This code does not include interpretation of the data.
     
    Code 94016 is used when a physician or lab technician provides the evaluation, interpretation and documentation of the spirometric tracings.
     
    Mary Mulholland, RN, CPC, a reimbursement analyst for the hospital of the University of Pennsylvania, department of medicine, warns coders that "the 'technical' (94015) and 'professional' (94016) portions of the service are not billed for and paid separately if the comprehensive service has already been billed."
      
    "Coders should check the Correct Coding Initiative (CCI) edits and make sure the physician's service is not bundled into a more comprehensive service," Mulholland says.
      

    Telephonic Spirometry Gains Credibility

    When 94014-94016 were introduced in 1999, they accompanied revisions of two existing codes, 94060 (bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]) for simple stress testing, and 94070 (prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics) for complex testing.
     
    "Codes 94014-94016 were initiated and designed to close a discrepancy in the existing spirometric code (94010), which did not adequately describe patient-initiated spirometric recording," O'Donohue says. The new codes recognized that:
     
  • The data-gathering machine or computer had to be hooked up;
     
  • The patient had to receive instructions from the medical facility to run the test and transmit the data, the trending and analysis of the data (separate from the physician's interpretation); and
     
  • The professional recalibration of the computer at designated intervals had to be performed.
      
    Overall Acceptance Lags Behind

    • Reimbursement continues to plague at-home monitoring of asthma and lung-transplant patients because not every state honors the service under Medicare. Many insurance carriers don't feel that telephonic spirometry has a viable and established history. For example, Pennsyl-vania Medicare did not pay for this evaluation until March 21, 2001.
     
    "Coders should check with third-party payers to determine if the procedure is billable," Mulholland says. "It is expensive for a practice to utilize technology if it is not reimbursed."

    Pennsylvania Defines Telephonic Spirometry

    To be covered under Pennsylvania's Medicare policy, a patient-initiated spirometry may be indicated following lung transplantation to monitor for problems such as rejection, infection or bronchiolitis obliterans or for patients diagnosed with severe asthma who meet all of three criteria:
     
    1. Severe asthma with both dyspnea at rest and FEV1 less than 40 percent predicted after bronchodilator administration
     
    2. Two hospitalizations or three emergency-room visits in the past 90 days for poorly controlled asthma or intercurrent respiratory infections
     
    3. Evidence of end-stage disease by any one of the following: hypoxemia at rest, hypercapnea; secondary polycythemia or coronary pulmonale/right heart failure determined by EKG, echocardiography or cardiac catheter.
     
    The policy further requires that measurements of these conditions should be "more than 14 days before or after a hospitalization or emergency-room visit, to ensure that they are stable baseline measurements and not markers of
    a more acute illness."
     
    To qualify for at-home, self-initiated monitoring, the patient must be mentally and physically capable of performing the test independently. Diagnosis codes that support the service's medical necessity are 491.8 (other chronic bronchitis), 493.00-493.02 (extrinsic asthma), 493.10-493.12 (intrinsic asthma), 493.20-493.22 (chronic obstructive asthma), 493.90-493.92 (asthma, unspecified), 996.84 (complications of transplanted lung) and V42.6 (organ or tissue replaced by transplanted lung).
     
    The best way to ensure reimbursement is to review your local medical review policies. Documentation must indicate medical necessity and include the spiral graphic representation of the data analyzed. And the medical record must include interpretation and evidence of computer tracings and be available upon request.

    Other Articles in this issue of

    Pulmonology Coding Alert

    View All